global climate change and nursing

Environmental Health

Barbara Sattler, RN, DrPH, FAAN Dr. Barbara Sattler has a diploma in nursing from Pilgrim State Psychiatric Center School of Nursing, a BS in political science from the University of Baltimore, and the MPH and DrPH from the Johns Hopkins University. She is a Professor at the University of San Francisco. She is a founding member of the Alliance of Nurses for Healthy Environments (www.enviRN.org), a national network of nurses who are addressing the integration of enviro n- mental health into our nursing education, practice, research, and policy/advocacy efforts. She has been working in the area of environmenta l health and nursing for three decades and has been involved in issues associated with air, water, food, and products, as well as cl imate change and energy policies as they relate to human health.

ADDITIONAL RESOURCES @ Evolve Website http://evolve.elsevier.com/Stanhope

Healthy People 2020 • WebLinks-Of special note see the link for these sites:

Envirotools www.enviRN.org: Alliance of Nurses for Healthy Environments

• National Library of Medicine online toxicology tutorial

OBJECTIVES

• Case Studies • Glossary

Answers to Practice Application Appendix • Appendix F.3: Comprehensive Occupational and

Environmental Health History

----------------------------------------------~- .. After reading this chapter, the student should be able to do the following: 1. Explain the relationship between the environment and

human health and disease. 2. Understand the key disciplines that inform nurses' work in

environmental health. 3. Apply the nursing process to the practice of environmental

health.

4. Describe legislative and regulatory policies that have influenced the impact of the environment on h ealth and disease patterns in communities.

5. Explain and compare the environmental health roles and skills for nurses practicing in public health, as well as those practicing in practice settings.

6. Incorporate environmental principles into practice.

KEY TERMS . . ;:· ·. . '.,, ·.-,.. ·, . - ... . - - ----------~-- - ------------~------

agent,p.222 bioaccumulated, p. 236 biomonitoring, p. 221 climate change, p. 223 compliance, p. 236 consumer confidence reports, p. 228 environment, p. 222 environmental justice, p. 236 environmental standards, p. 236 epidemiologic triangle, p. 222 epidemiology, p. 222 epigenetics, p. 221 geographic information systems, p. 222 host,p. 222 indoor air quality, p. 227 Industrial Hygiene Hierarchy of Controls, p. 232 methylmercury, p. 236

monitoring, p. 236 non-point sources, p. 226 permit, p. 236 permitting, p. 234 persistent bioaccumulative toxins, p. 236 persistent organic pollutants, p. 236 point sources, p. 226 precautionary principle, p. 231 right to know, p. 228 risk assessment, p. 228 risk communication, p. 233 risk management, p. 232 route of exposure, p. 233 toxicants, p. 229 toxicology, p. 221 - See Glossary for definitions

217

PART 3 Conceptual and Scientific Frameworks

Healthy People 2020 Objectives for Environmental Health Historical Context Environmental Health Sciences

Toxicology Epidemiology Geographic Information Systems Multidisciplinary Approaches

Climate Change Environmental Health Assessments

Information Sources Applying the Nursing Process to Environmental Health

Individual Environmental Exposure History Community-wide Environmental Health Assessment Tools

Environmental Exposure by Media Air Water Land and Soil Food

"Environmental health comprises those aspects of human health, including quality of life, that are determined by physical, chemical, biological, social, and psychosocial factors in th e environment. It also refers to the theory and

practice of assessing, correcting, controlling, and preven ting

those factors in the environment that can potentially affect

adversely the health of present and future generations." United Nations University, 1993 (UNU)

An estimated 24% of the global burden of disease and 23% of

all deaths can be attributed to environmental factors (WHO,

2015). As nurses there are a number of ways in which we can

define our environment. Our homes, schools, workplaces, and

communities are the environments in which most of us can be

found at any given time. Each location holds potential health

risks. As nurses, who are among the most trusted conveyors of

information to the public, it is our responsibility to understand

as much as possible about these risks- how to assess them, how

to eliminate or reduce them, how to communicate and educate

about them, and how to advocate for policies that support healthy environments.

We can also divide and examine the environment from the

perspective of the media in which environmental degradation takes place: air, water, soil, and food. And a third approach

would be to divide environmental exposures into categories:

biological, chemical, and radiological. In this chapter we will

look at the environment as comprehensively as possible and

consider the roles that nurses can have in assessing and address- ing environmental health.

Environmental exposures are rarely limited to one location

or to one source. For example, the broad category of pesticides

includes the insecticides we may use in our homes, the herbi-

cides we may use in our gardens, the pesticide residues on fruits and vegetables, and our antimicrobial soaps. Each of these

---------------- --- ~-----=--~ -- ... ---- - -------~

Right to Know Risk Assessment Vulnerable Populations

Children's Environmental Health Precautionary Principle Environmental Health Risk Reduction

Industrial Hygiene Hierarchy of Controls Risk Communication

Governmental Environmental Protection Policy and Advocacy

Environmental Justice and Environmental Health Disp arities

Environmental Health Threats from the Health Care Industry: New Opportunities for Advocacy

Referral Resources Roles for Nurses in Environmental Health

forms of pesticides comes with a potential health risk. If you have children and regularly use pesticides in your home, you

increase their risk of contracting leukemia. The more you use

insecticides, the greater the risk of leukemia (Metayer et al,

2013; Wigle et al, 2009; Turner et al, 2010; Brown, 2004) . The

childhood risk for leukemia increases if the mother was exposed

to pesticides, including occupational exposures (Bailey et al,

2014). Many playing fields where children compete in sports are

regularly sprayed with pesticides (Gilden et al, 2012).

In May 2010, the President's Cancer Panel proclaimed that

the contribution environmental carcinogens have made to the

burden of cancer in the United States has been grossly

underestimated. In addition to the main focus on chemical

carcinogens, the panel noted the importance of radiation

sources-ionizing and nonionizing. In a letter to President

Obama, they wrote: "The Panel urges you most strongly to use

the power of your office to remove the carcinogens and other

toxins from our food, water, and air that needlessly increase our

health care costs, cripple our Nation's productivity and devas-

tate American lives" (President's Cancer Panel, 2010). With this

call came a range of recommendations for reducing the risk of

cancer, both through individual choices and through national

policy. The recommendations for individuals are found in

Resource 10.A on the Evolve resources website.

Cancer is not the only health endpoint of environmental

exposures. An estimated 52 million homes in the United States

contain some lead-based paint that is associated with risks for

premature births, learning disabilities in children, hypertension

in adults, and many other health problems. Lead poisoning is

a completely preventable disease (Figure 10-1) . Of the top 20

environmental pollutants that were reported to the Environ-

mental Protection Agency (EPA), nearly three fourths were

known or suspected neurotoxins. Thirty million Americans

drink water that exceeds one or more of the EPA's safe drinking

FIG 10-1 Although lead is no longer allowed in house paint, over 34 million homes in the United States have lead-based paint U.S. Department of Housing and Urban Development (US DHUD, 2011 ). Pregnant women and parents who live in homes built before 1978 should be encouraged to have their homes tested for lead-based paint dust. (From State of Hawaii Depart- ment of Public Health. Available at http://hawaii .gov/health/ environ men ta 1/noise/asbestoslead/i mages2/ch i Id .jpg. Accessed December 15, 2010 )

water standards, and 50% of Americans live in an area that exceeds current national ambient air quality standards. When these standards are exceeded, there is an increased risk to the public for a wide range of health effects.

Although food labeling includes nutrition information, there is no requirement to label whether pesticides are used in the food production; whether nontherapeutic antibiotics were given to the livestock, poultry, or farmed fish; the presence of genetically modified organisms (GMOs) in a product; or whether recombinant bovine growth hormone (rBGH) was given to the dairy cows. Nurses have declared that the "right to know" about potentially hazardous exposures is one of the basic principles of environmental health (see Box 10-1). Nurses have a range of potential public health responsibilities in protecting the public from exposures and environmental health risks (ANA 2007).

A range of influences including genetics, socioeconomic status, and environmental exposures impact environmental health. In evaluating environmental exposures in a home, nurses' assessments can begin with a set of questions: What exposures can you identify in your own home? Do you use pesticides? Does your home have lead-based paint? (The age of a home is a good proxy for identifying the presence of

CHAPTER 10 Environmental Health

BOX 10-1 American Nurses Association's Principles of Environmental Health for Nursing Practice

The ANA calls for all nurses to understand basic environmental health con- cepts, invokes the Precautionary Principle, recognizes the multidisciplinary nature of environmental health, and promotes and supports nurses' roles in developing and maintaining environmentally healthy workplaces for them- selves and their patients. Principles include knowledge about environmental health and its effect on nursing practice, the Precautionary Principle, nurses' rights to work in a safe workplace and use materials, products, technology, and practices that reflect an evidence-based approach. Other principles relate to quality assessment of the environment, interdisciplinary work in environ- mental health, involvement in research, and support of nurses who advocate for a safe environment (ANA, 2007).

From American Nurses Assoc iation. Principles of environmental health for nursing practice, Silver Spring, MD, 2007.

lead-based paint because it is most likely found in homes built before 1978, when the use of lead was banned in household paint.) Is the paint chipping or peeling? Are any of your appli- ances or heat sources producing unhealthy levels of carbon monoxide? Have you checked your home for radon, the second largest cause of lung cancer in the United States? How about your workplace? Do you eat fish on a regular basis? (Some fish can have unhealthy levels of mercury.) A more comprehensive home assessment tool can be found in the Resources.

t>I LINKING CONTENT TO PRACTICE The Council on Linkages Between Academic and Public Health Practice, 2010 a key document that guides practice in both nursing and public health. Specifi- cally, the core competencies of the Council on Linkages includes, within the domain of public health science skills, a competency that says practitioners will apply "the basic public health sciences (including, but not limited to, environmental health sciences, health services administration, and social and behavioral health sciences) to public health policies and programs." The Quad Council of Public Health Nursing Organizations (2011 I further applies this competency specifically to public health nursing practice by adding that these skills are applied to public health nursing practice, policies, and programs. In 2007, the ANA adopted 10 principles of environmental health. Although all 1 D are essential, three are highlighted here. Nurses should know about envi- ronmental health concepts, participate in assessing the quality of the environ- ment in which they practice, and live and use the Precautionary Principle (which is discussed later in the chapter) to guide their work. A third principle points out that healthy environments are sustained through multidisciplinary collaboration, which is a key concept discussed throughout the chapter.

In 2010, the American Nurses Association (ANA) established an environ- mental health standard within the Scope and Standards of Professional Prac- tice that define the profession of nursing. This means that all nurses are now expected to have knowledge of and skills associated with environmental health.

Underpinning many of these organizational decisions to include environmen- tal health in nursing were the recommendations made in the report Nursing, Health and Environment(Pope, Snyder, and Mood, 1995) from the Institute of Medicine (IOM) of the National Academy of Science, which recommended that all nurses have a basic understanding of environmental health principles and integrate these principles into our practice, education, advocacy, policies, and research. In this chapter, we will explore the basic competencies recom- mended by the IOM. Box 10-2 presents the competencies.

PART 3 Conceptual and Scientific Frameworks

BOX 1 0-2 General Environmental Health Competencies for Nurses Recommended by the Institute of Medicine in Nursing, Health and the Environment

Basic Knowledge and Concepts All nurses should understand the scientific principles and underpinnings of the relationship between individuals or populations and the environment (includ- ing the wo rk environment). Thi s understand ing includes the basic mechanism and pathways of exposure to environmental health hazards, basic prevention and control strategies, the interprofessional nature of effective interventions, and the role of research.

Assessment and Referral All nurses should be able to successfully complete an environmental health history, recognize potentia l envi ronmenta l hazards and sentine l ill nesses, and make appropriate referrals for conditions with probable environmental causes. An essential component is the ability to access and provide information to clients and communities and to lo cate referral source s.

Advocacy, Ethics, and Risk Communication All nurses should be able to demonstrate knowledge of the role of advocacy (case and class), ethics, and risk communication in client care and community interven- tion with respect to the potential adverse effects of the environment on hea lth.

Legislation and Regulation All nurses should understand the policy framework and major pieces of leg- islation and regulations related to environmental health.

From Pope AM, Snyder MA, Mood LH, editors: Nursing, health, and environment, Washington, DC, 1995, Institute of Medicine, National Academy Press.

HEALTHY PEOPLE 2020 OBJECTIVES FOR ENVIRONMENTAL HEALTH Environmental health is one of the priority areas of the Healthy People 2020 objectives. The federal government has long recog- nized the importance of the relationship between environmen - tal risks and the underlying factors contributing to diseases. Selected examples of the Healthy People 2020 environmental health objectives are outlined in the following Healthy People 2020 box (U.S. Department of Health and Human Services, Healthy People 2020, 2010).

~ HEAL THY PEOPLE 2020 Examples of Objectives Related to Environmental Health

• EH-8.1: Eliminate elevated blood lead levels in children. • EH-9: Minimize the risks to human health and the environment posed by

hazardous sites. • EH -1 0: Reduce pesticide exposures that result in visits to the health care

facil ity. • EH-11 : Reduce the amount of toxic poll utants released into the environment. • EH-13: Reduce indoor allergen levels. • EH-18: Decrease the number of U.S. homes that are found to have lead-

based paint or related hazards.

From U.S. Department of Health and Human Services: Healthy People 2020. Available at http://www .healthypeople.gov/2020topicsobjectives 2020/default.aspx. Accessed January 1, 2011.

HISTORICAL CONTEXT Historically, nurses and physicians have been taught little about the environment and environmental threats to health. In the IOM report mentioned previously, quotes from Florence Night- ingale are used extensively, not only because she is a recognized symbol of nursing (i.e., the lady with the lamp), but also because of the central focus of environment in her practice and writings. She promoted the use of clean water and safe sanitary conditions and connected these elements to disease prevention. Early in the twentieth century, Lillian Wald, who coined the name "public health nurses;' spent her life improving the environment of the Henry Street neighborhood and encourag- ing her broad network of influential contacts to make changes in the physical environment, as well as social conditions that had direct health impacts. As modern day nurses are rediscover- ing environmental health, they are reintegrating many of the observations and skills that were practiced by early nurse pioneers.

There are still many communities like the ones that Lillian Wald served. Poverty is highly associated with health disparities and is also associated with disproportionately higher environ- mental exposure, which compounds the health disparities. Poverty is linked to living in substandard housing, living closer to hazardous waste sites, working in more hazardous jobs, having poorer nutrition, and having less access to quality health care (particularly preventative services). The term environmen- tal justice refers to the disproportionate environmental expo- sures that poor people and people of color experience in the United States and elsewhere, including lead paint dust exposure, the presence of pests (resulting in increased use of pesticides), and the use of supplemental heating sources that may cause dangerous carbon monoxide exposure. These combined cir- cumstances multiply the risk for health disparities.

It is important to note how we began to understand the relationship between environmental chemical exposures and their potential for harm. There are several ways in which we have historically made such discoveries: • When humans present with signs and symptoms that can be

connected to a specific chemical exposure. This may occur with acute pesticide poisoning or carbon monoxide poison- ing. It often occurs when workers are occupationally exposed. In such instances, the temporal and geographic relationships to the exposures and health effects help to identify health hazards in the environment ( e.g., the diagnosis of mesothe- lioma from asbestos exposure).

• When large accidental releases of chemicals occur in a com- munity that contaminate air, water, soil, or food, resulting in health effects. Such events show us how toxic chemicals are to humans and animals. For example, in the Love Canal incident outside of Buffalo, NY, an entire community was affected by hazardous chemicals that were dumped on the land where a housing development was built.

• In rare instances, when human environmental (and occupa- tional) epidemiologic studies have been performed. Through such studies, we have learned about the toxic effects of chemicals.

_____________________ C_H_A_P_T_E_R _10 __ E_n_v_ir_o_n_m_e_n_t_a_l _H_e_a_lt_h____.-

However, the most common way in which the relationships

between chemical exposures and health risks are identified is

when toxicologists study the effects of chemicals on animals and

then use models to estimate what the effects might be on

humans. This estimation process is called extrapolation. More

than 84,000 man-made (synthetic) chemical compounds have

been developed and introduced to our environment since

World War II, and we are most often reliant on the data that are

created in animal studies to warn us about their potential toxic-

ity to humans. For many of these chemicals, no toxicity data are

available. Surprisingly, there is no current requirement for orig-

inal toxicological research to be completed when a product or

process is being brought to market.

We live in a radically different environment compared to a

century ago. In addition to man-made pollutants contaminat-

ing our air, water, and food, many of the same pollutants

are now also found in our bodies (including breast milk). In

2001, the Centers for Disease Control and Prevention began

biomonitoring- the testing of human fluids and tissues for the

presence of potentially toxic chemicals, as part of its National

Health and Nutrition Exam Study. For instance, most Ameri-

cans carry pesticides, solvents, heavy metals and other poten -

tially toxic chemicals in their bodies. In 2005, an Environmental

Working Group tested the umbilical cord blood of newborn

babies and found that they also contained a similar range of

potentially harmful chemicals (EWG, 2005). Each of these

potentially hazardous substances creates a health risk. Nurses

need to understand the environmental exposures and the health

effects that may be associated with chemicals in order to develop

assessment tools, implement hazard reduction programs, and

advocate for safe and healthy chemical policies. For example,

when a woman is pregnant for the first time, this is an ideal time

for a nurse to help her assess and reduce or eliminate prevent-

able environmental health risks in her home and workplace. A

good environmental health history can help uncover a number

of exposures from the products she may use, the ways in which

she addresses pests in her home and garden, to the way in which

she may set up a new nursery room.

In the Resource Section under chemical policies, there are a

number of links to organizations that track federal and state

legislation on chemical issues.

ENVIRONMENTAL HEALTH SCIENCES

Toxicology Toxicology is the basic science that contributes to our under-

standing of health effects associated with chemical exposures.

Historically, it was referred to as the "study of poisons." Its

corollary in health care is pharmacology, which studies the

human health effects, both desirable and undesirable, associ-

ated with drugs. In toxicology, only the negative effects of chem-

ical exposures are studied. However, the key principles of

pharmacology and toxicology are the same. Just as the dose of

a drug makes the difference in its efficacy and its toxicity, the

quantity of an air or water pollutant to which we may be

exposed can determine whether or not ( and the extent to which)

we experience a risk of a health effect. In addition, the timing

of the exposure-over the human life span-can make a differ-

ence. For example, during embryonic and fetal development,

exposure to toxic chemicals can create immediate harm or

create a critical pathway for future disease. Very young children,

whose systems are still immature, are also more vulnerable

to exposures. In Harm's Way, an online report by Physicians

for Social Responsibility (with associated training materials)

describes the neurological damage that several common chemi-

cals can cause to developing children (Schettler et al, 2000). Just

as is true of medications, the same dose that one would give an

adult will have a much greater effect on a child and certainly on

a fetus. As we age our liver and renal functions slow, thereby

creating opportunities for toxic chemicals to accumulate, and

thus creating higher risks for harm.

Both drugs and pollutants can enter the body from a variety

of routes. Most drugs are given orally and absorbed by the

gastrointestinal (GI) tract. Water- and food-associated pollut-

ants, including pesticides and heavy metals, enter the body via

the digestive tract. Some drugs are administered as inhalants,

and some pollutants in the air (including indoor air) enter the

body via the lungs. Some drugs are applied topically. In work

settings, employees can receive dermal exposures from toxic

chemicals when they immerse their unprotected hands in

chemical solutions, especially solvents. Pollution can enter our

bodies via the lungs (inhalation), GI tract (ingestion), skin, and

even the mucous membranes (dermal absorption). Most chem-

icals cross the placental barrier and can affect the fetus, just as

most chemicals cross the blood- brain barrier. In addition to

direct damage to cells, tissues, organs and organ systems, there

can be changes to the DNA from chemical exposures that

can change gene expression, which in turn can predict disease.

This latter effect is the focus of a relatively new field of bio-

logical study: epigenetics. Scientists now understand that there

are many variables that predict disease outcomes, including

environmental exposures.

In the same way that we consider age, weight, other drugs

taken, and underlying health status of a client when we admin-

ister drugs, we must consider that these same factors can affect

an individual's response to environmental exposures. For

example, children are much more vulnerable to virtually all

pollutants. People who are immunosuppressed (people with

HIV/AIDS or those on immunosuppressant drugs like steroids

or anti-cancer medications) are especially at risk for foodborne

and waterborne pathogens. Because our communities are com-

prised of people of different ages and different health statuses,

their vulnerabilities to the effects of pollution will also vary.

When assessing a community's environmental health status, be

sure to review the general health status of the community and

to identify members who may have higher risk factors .

Chemicals that are similar are often grouped into categories

or "families" so that it is possible to understand the actions and

risks associated with those groupings. Examples are metals and

metallic compounds ( e.g., arsenic, cadmium, chromium, lead,

mercury), hydrocarbons (e.g., benzene, toluene, ketones, form-

aldehyde, trichloroethylene), irritant gases ( e.g., ammonia,

hydrochloric acid, sulfur dioxide, chlorine), chemical asphyxi-

ants (e.g., carbon monoxide, hydrogen sulfide, cyanides), and

PART 3 Conceptual and Scientific Frameworks

pesticides ( e.g., organophosphates, carbamates, chlorinated hydrocarbons). Although some common health risks exist within these families of chemicals, the possible health risks for each chemical should be evaluated individually when a poten- tial human exposure exists. The best source of peer-reviewed information for this is the National Library of Medicine (NLM). The NLM has a set of databases that are focused on toxicology and environmental health called TOXNET. You will find the link to several of these helpful informational programs and data- bases in the Referral Resources.

Epidemiology Whereas toxicology is the science that studies the poisonous effects of chemicals, epidemiology is the science that helps us understand the strength of the association between exposures and health effects. Epidemiology is often used for occupation - ally related illnesses but has been used less often to study envi- ronmentally related diseases. It is difficult to characterize and/ or distinguish among the many exposures that we all experi- ence, and it can be challenging to find control groups when the environmental exposure of concern is in the air, water, or food.

Epidemiologic studies have helped us to understand the association between learning disabilities and exposure to lead-based paint dust, asthma exacerbation and air pollution (Smargiassi et al, 2014; Habre et al, 2014), and GI disease and waterborne Cryptosporidia (Yoder et al, 2012). Environmental surveillance, such as childhood lead registries, provides data with which to track and analyze incidence and prevalence of health outcomes. The results of such analyses can help to target scarce public health resources. Scientists are now approaching epidemiology at the molecular level, looking at gene/environment interactions.

As described in Chapter 12, three major concepts-agent, host, and environment-form the classic epidemiologic tri- angle. (See Figure 12-2, A in Chapter 12.) This simple model belies the often-complex relationships between agent, which may include chemical mixtures (i.e., more than one agent); host, which may refer to a community with people of multiple ages, genders, ethnicities, cultures, and disease states; and envi- ronment, which may include dynamic factors such as air, water, soil, and food, as well as temperature, humidity, and wind. Limitations of environmental epidemiologic data include reli- ance on occupational health studies to characterize certain toxic exposures. The occupational health studies were performed on healthy adult workers whose biological systems were different from those of neonates, pregnant women, children, people who are immunosuppressed, and the elderly. Nevertheless, nurses can review epidemiologic studies regarding exposures of concern to their communities and use epidemiologic tech- niques to assess environmental risks in communities.

Geographic Information Systems Another research tool for environmental health studies is geographic information systems (GIS), a methodology that requires the coding of data so that it is related spatially to a place on Earth. By layering geographically related data, maps can be created to note where the data may be related. For instance, by

taking a data set that geographically notes where children under 10 years of age live and overlaying another data set that notes geographical areas designated by the age of housing stock, a public health nurse could see where there are the largest number of children who live in areas with older housing stock. With this information, the nurse could target a lead surveillance and edu- cational program. Nurse researcher Mona Choi used GIS to study the relationship between air pollution and emergency visits for cardiovascular and pulmonary diagnosis. Community- based maps that are created using GIS technologies are helpful in educating community members and local policy makers. The maps can provide useful graphic depictions of public health problems.

Environmental health requires a combination of tried and tested nursing tools mixed with new tools, such as GIS, and the recognition that many disciplines may be involved in the iden- tification and the resolution of environmental health issues.

Nurse scientists Wade Hill and Patricia Butterfield (2006) developed a model for environmental risk interventions, which can be provided by public health nurses, that improves chil- dren's health by addressing home-related sources such as lead paint, contaminated drinking water, and environmental tobacco smoke, among others. These risks can cause health effects ranging from minor learning deficiencies to serious and life- threatening diseases such as cancer. Many of the environmental risks children encountered were prevented or reduced by taking practical and affordable steps. Butterfield developed an envi- ronmental justice framework by which to consider environ- mental exposures in rural areas (Butterfield & Postma, 2009).

Multidisciplinary Approaches In addition to toxicology and epidemiology, there are a number of earth sciences to help us understand how pollutants travel in air, water, and soil. Geologists, meteorologists, physicists, and chemists all contribute information to help explain how and when humans may be exposed to hazardous chemicals, radia- tion (e.g., radon), and biological contaminants. Key public health professionals include food safety specialists, sanitarians, radiation specialists, and industrial hygienists.

The nature of environmental health demands a multidisci- plinary approach to assess and reduce/eliminate environmental health risks. For instance, to assess and address a lead-based paint poisoning case we might include a housing inspector with expertise in lead-based paint or a sanitarian to assess the lead- assodated health risks in the home; clinical specialists to manage the client's health needs; laboratories to assess the blood lead levels, as well as lead levels in the paint and house dust and drinking water; and then lead-based paint remediation special- ists to reduce the lead-based paint risk in the home.

We might also add a health educator and outreach worker to educate the family and encourage compliance with environ - mental health behaviors and clinical treatments. And finally, we may need to work with public health lawyers to address non- compliant landlords. Such combined approaches could poten- tially involve the local health department, the state department of environmental protection, the housing department, a primary and tertiary care setting, public or private sector labs, and the

____________________ C_H_A_P_T_E_R_ 1_0_ E_n_v_ir_o_n_m_e_n_t_a_l _H_e_al_th _ _

legal system. The nurse's responsibility is to understand the

roles of each respective agency and organization, know the

public health laws (particularly as they pertain to lead-based

paint poisoning in their communities), and work with the com-

munity to coordinate services to meet their needs. The nurse

also might set up a blood lead screening program through the

local health department, educate local health providers to

encourage them to systematically test children for lead poison-

ing, and/or work with advocacy organizations to improve the

condition oflocal housing stock. Note that although lead-based

paint is no longer in use in the United States, it is still widely

used in developing countries.

@® FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

Targeted Competency: Function effectively wi thin nursing and interprofes-

sional teams, fostering open communication, mutual respect, and shared

decision making to achieve quality client care.

Knowledge: Describe scopes of practice and roles of health care team

members. Skills: Assume the role of team member or leader based on the situation.

Attitudes: Value the perspecti ves and expertise of all health team members.

Safety Question: One of the objectives of Healthy People 2020 related to

environmental health is "Reduce pesticide exposures that result in visits

to a health care facility" (ED 8-10). The public health nurse, who is working

on a project to help mothers learn parenting skills, visits a new mother who

lives and wo rks on a large farm. When the nurse drives into the farm on

her way to the housing where workers live, she sees that the fields are

being sprayed with pesticides from a truc k and that two young children are

riding in the back of the truck. What action should she take?

Answer: At the individual level, she should talk with the owner or manager

of the farm and remind him or her of the toxicity of pesticides and the

danger to those who are in the vicinity of the spraying. She should recom -

mend that he or she not allow anyone to ride in the open portion of the

vehicle and that the driver should leave the window closed and wear a

mask to protect his or her nose and mouth .

Systems level: She should identify areas where the workers on the farms

congregate, such as churches, social halls, and so forth . Then she should

ask if she could provide an educational program on the dangers of coming

into contact with pesticides. She could distribute pamphlets about this

hazard in local venues where both farm managers and workers will be able

to access them. What else might the nurse do?

CLIMATE CHANGE

According to the World Health Organization, "climate change

is a significant and emerging threat to public health, and changes

the way we must look at protecting vulnerable populations"

(WHO, 2014b). The 2014 report of the Intergovernmental

Program on Climate Change, a WHO-related group of scien-

tists, concludes that "climate change will act mainly, at least

until the middle of this century, by exacerbating health prob-

lems that already exist, and the largest risks will apply in popula-

tions that are currently most affected by climate-related diseases"

(IPCC, 2014), In the United States we are already seeing

some of the earlier climate change predictions materialize: long-

term warming trends, extreme weather conditions, as well as

disruption in water supplies, agriculture, ecosystems, and

coastal communities. There are two concurrent categories of roles for nurses: miti-

gation and response. There is still much we can do to mitigate

the steep upward slope that we are now observing for tempera-

tures, CO2 levels, desertification, and sea water levels. Working

at the individual, community, institutional (school, hospital,

etc.), and governmental levels, there is much work to be done

to ensure energy-conserving policies and practices, rational

transportation practices, and changes in our consumption

patterns. Regarding response preparation, public health nurses must

lead the development of contingencies for long-term, high-heat

weather conditions, as well as increased storm activities ( that

include more severe storm patterns), more extensive fires in

areas prone to fires, and the associated disaster preparedness.

For more on disaster preparedness, see Chapter 23 on nurses'

roles in disaster management. Nurses should also be prepared

for threats to food security from shifting weather patterns that

may deter/eliminate food production and for acute shifts of

populations as they migrate away from low-lying, coastal

regions or other areas acutely affected by storm or fire damage.

These shifts are likely to create climate change-related refugee

migrations. The oil spill in the Gulf of Mexico was the largest in history

and caused devastating damage. It is expected that its effects on

birds, fish, and other sea animals, as well as the environment,

will continue for many more years. Since fish populations were

affected, many fishermen lost their jobs and the livelihood that

they knew (Gulf Oil Spill, n.d.). This type of ecosystem destruc-

tion and economic disruption will be typical if we do not

address climate change and our associated need to reduce/

eliminate our reliance on fossil fuels (gas, oil, coal). It is impor-

tant to explore the science underpinning climate change, con-

sider the human and ecological health threats, and reflect on

nurses emerging roles as climate change unfold.

ENVIRONMENTAL HEALTH ASSESSMENTS

There are a number of ways to assess environmental health risks

in a community. For example, risks can be assessed by medium:

air, water, soil, or food. Or exposures could be listed according

to urban, rural, or suburban settings, with many exposures

being common to all three settings. Nurses may also divide the

environment into functional locations such as home, school,

workplace, and community. Each of these locations will have

unique environmental exposures, as well as overlapping expo-

sures. For instance, ethylene oxide, the toxic gas that is used in

the sterilizing equipment in hospitals, is typically found only in

a workplace. However, pesticides might be found in any of the

four areas. When assessing environments, be sure to determine

if an exposure is in the air, water, soil, and/or food and whether

it is a chemical, biological, or radiological exposure.

Information Sources The NLM has developed some of the most useful, comprehen-

sive, and reliable sources of environmental health information.

PART 3 Conceptual and Scientific Frameworks

The NLM's website for ToxTown (http: //toxtown.nlm.nih.gov/) is one of the best places to start when developing environmental assessment skills. Within ToxTown, there is a Household Prod- ucts page where nurses can research common products such as those for personal care, cleaning, pet care, lawn care, and others to see the potential health risks that may be associated with them. Also, chemicals can be researched by brand or chemical name or by Chemical Abstract System number. (The NLM website can be accessed at www.nlm.nih.gov; at the website, search for the environmental assessment section.)

Also within ToxTown, you can search for general environ- mental health risks in the "city;' "town;' and "farm;' or even go to a "US-Mexico Border Community:' While in the virtual "city" you can visit a hair salon, hospital, or funeral home to see what kinds of environmental health risks are posed in such places. ToxTown brings together governmental and well-vetted nongovernmental sources for a rich web resource in which to learn about environmental health.

Another database that is specific to personal care products, which includes over 68,000 products that can be searched by brand name and specific product descriptors, is the Skin Deep database (http://www.ewg.org/skindeep/). The Safe Cosmetics website, which links to the Skin Deep database, additionally provides information on better protecting your health by select- ing products that have simpler ingredients and fewer synthetic chemicals. For example, the site points out that even top-selling brands of natural and organic products may have some toxic components. Specifically, they say that some top-selling herbal shampoos contain 1,4-dioxane, a synthetic chemical carcino- gen. They also comment on the number of lipsticks that they found to contain lead. Note that in both the NLM and the Safe Cosmetics databases, the information is predicated on what the manufacturers place on the label as ingredients (Figure 10-2). If the manufacturer claims that a component is a "trade secret;' it will not appear on the label. Rarely are the chemicals that make up a "fragrance" listed on the label; instead, it is likely to only read "fragrance" on the label. And finally ( and this is espe- cially true with pesticides), the label may merely say "inerts"

FIG 10-2 Some of the chemicals in our personal care products can be hazardous to our health. You can look up the chemicals in your products and learn about the potential hea lth risks by going to the Skin Deep database: http://www.ewg.org/skindeep/. (Photo from the U.S. Food and Drug Administration . Available at http://www. fda. gov/Cosmetics/defau It. htm ?w vsessionid= 1724ec6bbda343c6b7d0e092db6c2f30.)

without any further information about their chemical identity. Thus, it is sometimes impossible to make a true assessment about the health risks based on the information provided by the manufacturer.

One of the ANA Environmental Health Principles is the tenet of the "Right to Know;' which recommends the need for access to all information necessary to make informed decisions and protect our health. There are still a number of ways in which full disclosure of chemical exposure is lacking in terms of air and water pollution, food contents, and product ingredi- ents. Nurses, both individually and through their professional organizations, can advocate for increasing access to information through "right to know," labeling, and other legislative and regulatory efforts.

APPLYING THE NURSING PROCESS TO ENVIRONMENTAL HEALTH If you suspect that a client's health problem is being influenced by environmental factors, follow the nursing process and note the environmental aspects of the problem in every step of the process: 1. Assessment. Use your observational skills ( e.g., windshield

surveys); interview community members; ask your individ- ual clients; and ask the families of your clients. Review web- based data on existing exposures, such as air and water pollution monitoring data, drinking water testing, and con- taminated soil. Relate the disease and the environmental factors in the diagnosis.

2. Planning. Look at community policy and laws as methods to facilitate the care needs for the client; include environmental health personnel in planning.

3. Intervention. Coordinate medical, nursing, and public health actions to meet the client's needs. Ensure that the affected person or family is referred for appropriate clinical care.

4. Evaluation. Examine criteria that include the immediate and long-term responses of the client as well as the recidivism of the problem for the client.

Individual Environmental Exposure History When working with individuals, it is important to include envi- ronmental health risks as part of a client's history. Ask certain questions to assess exposures that may occur in all of the set- tings in which they spend time. A helpful mnemonic was devel- oped to assist health professionals in remembering the areas of concern when taking an environmental history: "I PREPARE." The mnemonic (see Box 10-3) can be used when interviewing an individual client or when assessing a family or it can be adapted for use with a group of community members.

Community-wide Environmental Health Assessment Tools Nurses have developed several exposure assessment tools, including forms for pregnant women, home and school assess- ments, community-wide assessments, and assessment tools for hospital-related exposures. The web links on the Evolve site for this book include several examples of environmental assess- ment tools.

CHAPTER 10 Environmental Health

BOX 1 0 - 3 The "I PREPARE" Mnemonic from the Agency for Toxic S ubstances and

Disease Registry

Investigate Potential Exposures

Present Work

Residence Environmental Concerns

Past Work Activities Referrals and Resourc es

Educate Do an Exposure History to :

Identify current or past exposures.

Reduce or el iminate current exposures.

Reduce adverse health effects.

Taking an Exposure History: Questions to Consider

I-Investigate Potential Exposures

Investigate potential exposures by asking:

Ha ve you ever felt sick after coming in contact wi th a chemical, such as a

pesticide or other substances?

Do you have any symptoms that improve when you are away from your home

or work?

P-Present Work At your present work:

Are yo u exposed to solvents, dusts, fumes, radiation, pesticides, or other

chemicals? Are you exposed to loud noise?

Do you know whe re to find material safety data sheets for chemicals with wh ich

you work? Do you wear personal protective equipment?

Are work clothes worn home?

Do coworkers ha ve similar health problems?

R-Residence When was your residence built?

What type of heating do you have?

Have you recently remodeled your home?

What chemicals are stored on your property?

Where is the source of you r drinking water?

E-Environmental Concerns

Are there environmental concerns in your neighborhood (i.e., air, water, so il)?

What types of industries or farms are near your home?

Do you live near a hazardous waste site or landfill?

P-Past Work What are your past work experiences?

What job did you have for the longest period of time? Have you ever been in

the military, worked on a farm, or done vo lunteer or seasonal work?

A-Activities What activities and hobbies do you and your family pursue?

Do you burn, solder, or melt any products?

Do you garden, fish, or hunt?

Do you eat what you catch or grow?

Do you use pesticides?

Do you engage in any alternative healing or cultural practices?

R-Referrals and Resources Use these key referrals and resources:

Environmental Protection Agency (www.epa.gov)

National Library of Medicine-TOXNET Programs (www.nlm.nih .gov)

Agency for Toxic Substances and Disease Registry (www.atsdr.cdc.gov)

Association of Occupational and Environmental Clinics (www.aoec.org)

Occupational Safety and Health Administration (www.osha.gov)

EnviRN website (www.enviRN.umaryland.edu)

Local Health Department, En vironmen tal Agency, Poison Control Center

£-Educate (A Checklist) Are materials available to educate the client?

Are alternatives available to minimize the risk of exposure?

Have prevention strategies been discussed?

What is the plan for follow-up?

Prepared by Grace Paranzino, RN, MPH, for th e Agency for Toxic Substa nces and Disease Registry. For more information, contact ATS DR at

1-888-42-ATSDR or visit ATSDR's website at http://www.atsdr.cdc .gov.

A windshield survey is a helpful first step in understanding

the potential environmental health risks in a community. If the

community is urban, the age and condition of the housing stock

and potential trash problems (and the associated pest prob-

lems) can be determined easily by driving around the neigh-

borhood. Note proximity to factories, dump sites, major

transportation routes, and other sources of pollution. In rural

communities, note if and when there are aerial and other

types of pesticide and herbicide spraying, if people rely on

wood-burning stoves, if there are industrial-type agricultural

practices, and/or if there are contaminated waterways. Using

ToxTown can really help with identifying health risks associated

with the observations from a windshield survey.

You may not be able to "see" the pollution that is in your

community, but the U.S. Environmental Protection Agency's

website, EnviroFACTS, can help identify air, water, and soil pol-

lution in your area by entering your ZIP code. Nurses are often

surprised to find out what is being released into their neighbor-

hood's water and air.

The Right to Know section of this chapter contains a descrip -

tion of the types of information that are available to the public

about air and water pollutants, drinking water quality, and other

environmental sources or exposures. Armed with this informa-

tion, a nurse can create a significant environmental health map

of a community. In addition, Appendix F.3 presents an example

of an occupational and environmental assessment.

While we observe environmental health risks in our com-

munities, it is equally important for us to identify the positive

environmental contributors to our communities. Settings that

connect people to nature-parks, green spaces, and beaches-

are incredible assets to communities. The term nature-deficit

disorder was coined by author Richard Louv in his book Last

Child in the Woods to describe what happens to young people

who become disconnected from the natural world. Louv links

this lack of nature to some of the most disturbing childhood

trends, such as the rises in obesity, attention disorders, and

depression (Louv, 2005). Policy makers, educators, and chil-

dren's health advocates are considering their roles in addressing

PART 3 Conceptual and Scientific Frameworks

Pollutant Emissions

FIG 10-3 Air pollution comes from a wide range of sources. EPA's EnviroFACTS site allows you to check the air and other pollutants in your ZIP code. http://www.epa .gov/env iro/. (Figure from the National Park Service, Sources of Air Pollution. Retrieved March 16, 2014 from http ://www2. nature. nps .gov/a ir/aqbas ics/sources. cf m .)

this issue. The National Park Service works to bring more people to parks-local, state, and national.

Man-made "green" spaces such as community gardens, streetscapes, bike paths, and water features can positively contribute to a community's health and sense of well- being. Recent attention has been paid to the importance of "walkable communities," access to nature, and other concerns included in discussions about "Smart Growth" or "Sustainable Communities."

Some new suburban developments are designing space for agriculture in the form of Community Sustainable Agriculture (CSA), a model of local agriculture in which community members purchase shares in the spring and receive fruits and vegetables as they are harvested. Also in this model, community members have the option to volunteer on the farm. This creative new community design addresses a number of public health issues-obesity, depression/social isolation, poor nutrition-by getting people outside and moving, creating opportunities for building supportive relationships, and pro- viding fresh produce.

ENVIRONMENTAL EXPOSURE BY MEDIA ------- - --- ------ - Many of the environmental protection regulations are based on the "medium" in which pollutants are carried-air, water, and soil. Additionally, chemical, biological, and radiological hazards can be found in food and consumer products. For air, water, and soil, the U.S. EPA and its state-level equivalents are the primary regulatory agencies. However, the EPA also regulates pesticides used in agriculture. The U.S. Department of Agricul- ture focuses substantially on pathogens in our food supply.

Air Air pollution is a significant contributor to human health prob- lems, and a sign that regulatory efforts are not completely

BOX 1 0-4 U.S. EPA Criteria Air Pollutants-National Ambient Air Quality Standards (NAAOS) Ozone (ground level) Sulfur dioxide Nitrogen dioxide

Particulate matter Carbon monoxide Lea d

effective. Nurses can have a role in addressing both the health problems and the policies affecting the exposures. Air pollution is divided into two major categories: point source and non- point source (see Figure 10-3). Point sources are individual, identifiable sources such as smokestacks. They are sometimes ref erred to as fixed sites. Non- point sources come from more diffuse exposures. For instance, the largest non-point source of air pollution is from mobile sources such as cars and trucks, which are the greatest single source of air pollution in the United States. The Clean Air Act regulates air pollution from point and non-point sources. Box 10-4 presents a list of the air pollutants that comprise the "criteria pollutants"-a set of pol- lutants that the EPA uses to gauge the overall air quality. The burning of fossil fuel (e.g., diesel fuel, industrial boilers, and coal-fired power plants) and waste incineration are two other major contributors. Health effects associated with air pollution include asthma and other respiratory diseases, cardiovascular diseases (including cardiac disorders and hypertension), cancer, immunological effects, and reproductive health problems including birth defects, infant death, and neurological prob- lems. For children with asthma the additional insult of living near a fixed source of pollution can create additional health risks (Smargiassi et al, 2014).

The single greatest source of mercury in our air is coal-fired power plants. Many people do not know that a pea-sized amount of mercury is sufficient to contaminate a 25-acre lake

and make its fish unfit to eat. Mercury, like lead, is an element and it persists in our fresh waterways and oceans from which we continue to get our fish. We cannot readily take these ele- ments out once they have been released into the environment; our job is to focus on policies that prevent them from being released.

Indoor air quality (IAQ) is a growing public health concern in office buildings, schools, and homes and is reflected in the alarming rise in asthma incidence in the United States, particu- larly among children. The EPA and the American Lung Associa- tion both provide excellent materials on IAQ. The EPA has a free kit called IAQ: Tools for Schools, which includes a video and a number of helpful materials for people interested in improv- ing the air quality in a school building.

Radon, a naturally occurring radioactive element that is found in the earth's crust and can seep into basements and into groundwater, is the second leading cause of lung cancer in the United States, second only to smoking. To learn more about this important environmental exposure, read more in the Resource Section. Other major culprits contributing to poor indoor air are carbon monoxide, formaldehyde, dusts, molds, pests and pets, pesticides, cleaning and personal care products (particu - larly aerosols), lead, and of course environmental tobacco smoke.

Because environmental health implies a relationship between the environment and our health, we must assess both the envi- ronmental exposures and the human health status within a community. Health status is assessed by using local, state, and national health data or by collecting our own data, or a combi- nation of the two. As we learn more about the exposures in our communities and their known or suspected health effects, we can target the health statistics we wish to review or collect.

Water Water is necessary for all life forms. Human bodies consist of 70% water. Only 2.5% of the water on this planet is fresh water; the rest is salt water. Much of the fresh water is in the polar icecaps, whereas groundwater makes up most of what remains, leaving only 0.01 % in lakes, creeks, streams, rivers, and rainfalls. People's lives are inextricably tied to safe and adequate water. Water is necessary for the production of food. In the United States, all public water suppliers must test their water in accor- dance with the EP~s safe drinking water standards and they must summarize the results of their testing annually and make them available to their customers-those who pay water bills. The technical term for these reports is Consumer Confidence Reports (CCR). Nurses can request these summaries from the water suppliers that serve their communities. Private wells are not regulated and need not be tested except when they are first drilled. Nurses should encourage people with private wells to have them tested annually, especially in agricultural areas where pesticides are applied.

Pollution discharges into water bodies from industries and from wastewater treatment systems can contribute to the deg- radation of water quality. An additional source of pollution in our waters is pharmaceuticals used for humans and animals. The U.S. Geological Service has found antibiotics, codeine,

CHAPTER 10 Environmental Health

17~-estradiol (an estrogen replacement hormone), and acet- aminophen (Tylenol), as well as a variety of endocrine disrupt- ing chemicals, in measurable quantities in U.S. streams and rivers.

Water quality is also affected by non-point sources of pollu- tion, such as storm water runoff from paved roads and parking lots, erosion from clear-cut tracts of land for timbering and mining, and runoff from chemicals added to soils such as pes- ticides and fertilizers. Soil erosion is another huge public health threat in the making as it is decreasing the amount of soil that can sustain agriculture and the global food supply. Eighty percent ( 80%) of the world's forests are gone, which is contrib- uting to massive erosion of farmable soil and deterring the flow of and healthy biotic life in creeks and rivers.

Land and Soil Current and past land use can affect a community's health. Local governments dictate land use through zoning laws. For instance, zoning decisions can determine if a community will have a hazardous waste site built in its neighborhood or whether the land can be used only for residential purposes (housing). Historically, communities in which poor people and people of color live have been more likely to have undesirable and unhealthy industries, railway lines, and hazardous waste sites. In many communities, prior use of the land has left a legacy of unhealthy contaminants. There are two designations for lands that may be contaminated: Superfund sites (highly contami- nated sites, with associated health threats that are designated by the EPA) and Brownfield sites (land that has been used previ- ously and which is now slated for redevelopment). Public health nurses can play an important role with both Superfund and Brownfield sites related to the health assessment. Funds are available through both the Superfund and Brownfield laws to engage the community and to do health assessments.

Food Many health risks are associated with food and food produc- tion. In recent years, we have seen foodborne illnesses associated with Salmonella and Escherichia coli H:0157:H7 in chicken, eggs, and meats. Good food preparation practices, such as proper washing and using adequate cooking temperatures and time, can prevent foodborne illnesses associated with most patho- gens. Local health departments are responsible for monitoring food establishments (restaurants, food trucks, etc.) in the com- munity, and the U.S. Department of Agriculture is responsible for oversight of meat, poultry, fish, and produce production.

However, there are also environmental health risks posed by the presence of pesticide residues in our food; the use of recom- binant bovine growth hormone (rBGH), which is given to many dairy cows; the administration of antibiotics to beef cattle, pigs, and chickens at nontherapeutic doses that are given to promote growth; and the use of genetically modified organisms (GMOs) for genetically engineered crops. In the Resources Section, there are a number of websites through which you can find out more information about food-related public health issues.

When assessing a community's environmental health risks, a nurse must consider air, water, soil, and food. It is important

PART 3 Conceptual and Scientific Frameworks

that nurses understand the term "organic" regarding food label-

ing. If a food is labeled "Certified Organic" this is a meaningful

term that has a legal USDA definition. The legal definition

stands for foods that have been produced without the use of

pesticides, genetically modified organisms (GMOs), or unnec-

essary (nontherapeutic) use of antibiotics. If a food is merely

labeled "organic;' the consumer does not have the same guar-

antee for what chemicals or farming practices have been used.

When purchasing foods directly from farmers through farm

stands or farmers' markets, consumers can directly ask about

the chemicals and farm practices.

RIGHT TO KNOW Several environmental statutes give the public the right to know

about the hazardous chemicals in the environment. Under one

of the "right to know" laws, health professionals and commu-

nity members can easily access key information by ZIP code

regarding major sources of pollution that are being emitted into

the air or water in their community. The EPA has an Envirofacts

section on its website that provides several sources of exposure

data by ZIP code (http://www.epa.gov/enviro/). Nurses can access drinking water consumer confidence

reports, sometimes referred to as "right to know" reports, to

determine what pollutants have been found in the drinking

water. If the drinking water poses an immediate health threat, the water provider must send emergency warnings out to the

community via the local newspapers, radios, and television. If there is a biological hazard (microbial) in the water, the health

notice may suggest boiling the water or not drinking it at all. If the hazard is chemical, boiling the water may not be helpful

because that may simply concentrate the chemical. A federal

law, the Freedom of Information Act, allows citizens to request

many kinds of public documents, including information about

environmental permits and inspections of facilities in your

communities. Employees have the right to know about the hazardous

chemicals with which they work through the federal Hazard

Communication Standard, which is under the purview of the

Occupational Safety and Health Administration (OSHA). This

standard requires employers (including hospitals) to maintain

a list of all of the potentially hazardous chemicals that are used

on site. Each of these chemicals should have an associated

chemical information sheet known as a material safety data

sheet (MSDS), which is written by the chemical manufacturer.

These MSDSs are to be made available to any employee or his

or her representative ( e.g., a union) and should provide infor-

mation about the chemicals that constitute the product, the

health risks, and any special g_uidance on safe use or handling

(e.g., requirements for protective gloves or respiratory protec-

tion). For more extensive information on workplace health and

safety, see http://www.osha.gov.

RISK ASSESSMENT Currently, the EPA uses a process referred to as "risk assess-

ment" when they develop health-based standards. The term risk

assessment refers to a process to determine the probability of

a health threat associated with an exposure. The following illus-

tration of a chemical exposure demonstrates the four phases to

a risk assessment: 1. Determining if a chemical is known to be associated with

negative health effects (in animals or humans). For this, we

rely on toxicological and/or epidemiologic data. (Remember,

the available toxicological data will probably be based on animal studies and these studies estimate the potential effects

on humans, whereas the results of human epidemiologic

studies will be for human health effects.) 2. Determining whether the chemical has been released into

the environment-into the air, water, soil, or food. This is

accomplished by testing for the presence of the suspected

chemical in the various media (air, water, soil, food). Envi-

ronmental professionals such as air and water pollution sci-

entists, environmental engineers, meteorologists, and others

might be involved in this activity. When doing a risk assess-

ment, it is important to note if there are multiple sources of

the chemical in question. For example, is lead found in the

drinking water, the ambient air, and in the paint within the houses of a given community?

3. Estimating how much and by which route of entry the chem-

ical might enter the human body-inhalation, ingestion,

dermally, or in utero exposure. This estimate can be based

on a one-time exposure, a short-term exposure, or a pro-

jected lifetime exposure. (When federal standards are created

for air, water, and other pollutants, they are based on an

estimation of a lifetime exposure. However, in workplace

settings the chemical exposure standards are based on an

average exposure during a typical 8-hour work shift or set

for a maximum exposure level that should not be exceeded.)

4. Characterizing the risk assessment process and taking into

account all three of the previous steps. Is the chemical toxic?

What is the source and amount of the exposure? What is the

route and duration of the exposure for humans? The final

synthesis attempts to predict the potential for harm based

on the estimated exposure.

All science is subject to interpretation, and so is risk assess-

ment. The reason that environmental laws are so often conten-

tious is because there are economic interests at stake and not

just public or ecological health concerns. In translating the risk

assessment results for the purposes of policy development and

recommendation for risk reduction activities, there are often

several interpretations of each of the risk assessment steps that

then result in differing recommendations for health-based stan-

dards. There are also areas of scientific uncertainty that contrib-

ute to variations in assessment of risk. It is critical to have public

health voices in the debates. The American Public Health Asso-

ciation is actively engaged on major policy debates through the

Environment Section.

VULNERABLE POPULATIONS

Many of the social determinants of health contribute to the risk

levels associated with environmental exposures. Poor people

who live in low-income communities are more often housed in

substandard housing (with attendant risks of chipping and peeling paint, pests, and unsafe neighborhoods), live closer to pollution sources, are employed in more dangerous occupations, and have less access to healthy food options. In addition, vulner- ability is variable through the human life cycle. The embryo and fetus are the most vulnerable to chemical exposures because of the rapid growth of cells and the development of tissues, organs, and organ systems. Following is a section on children's special vulnerabilities. The very young and the very old also are vulner- able because their body systems are either still developing or are less efficient, respectively. For more information about the special vulnerabilities of the elderly, see the EPA's dedicated information site on older Americans (www.epa.gov/aging/) and look at their report "Growing Smarter/Living Healthier: A Guide to Smart Growth and Active Aging (http://www.epa.gov/aging/ docs/growing-smarter-living-healthier.pd£). For more informa- tion on the effects of perinatal exposures, the University of California San Francisco has a Program on Reproduction and Environment that provides informational webinars, factsheets, the latest research and policy/advocacy information available at http://www.prhe.ucsf.edu.

Children's Environmental Health Consider some of the current childhood health statistics with which environmental factors are associated: approximately 9% of American children suffer from asthma, with higher rates in black children (CDC, 2012). About 20% of the world's children and adolescents suffer from a mental health problem (WHO, n.d.), and this statistic is mirrored in the United States (DHHS, 2005). The CDC monitoring system for autism spectrum dis- orders reports that the prevalence of autism among 8-year-olds in the United States is 1 in every 68 children (CDC, 2014a). The global prevalence of autism has increased twentyfold to thirty- fold since the earliest epidemiologic studies were conducted in the late 1960s and early 1970s. And millions of homes in the United States continue to have chipping and peeling lead-based paint.

Developmental disorders and attention deficit hyperactivity disorder (ADHD) collectively are estimated to affect 17% of school-age children (AHRQ, 2002; Anney et al, 2006). Child obesity has doubled and adolescent obesity has more than qua- drupled in the last 30 years (CDC, 2014b). From 1975 to 2010 the incidence rates for 4 cancer types, acute lymphocytic leuke- mia, non-Hodgkin lymphoma, acute myeloid leukemia, and testicular germ cell tumors, increased in children (ACS, 2014). The most common cancers among children ages O through 14 are acute lymphocytic leukemia, brain and CNS, neuroblas - toma, and non-Hodgkin lymphoma (ACS, 2014, p. 25). "All cancers involve the malfunction of genes that control cell growth and division. Only a small proportion of cancers are strongly hereditary ... " (ACS, 2014, p. 1). According to the American Cancer Society (ACS), about 5% of all cancers are strongly associated with heredity (ACS, 2010). The rest occur from environmental exposures, lifestyle choices ( diet, smoking, etc.), and other factors during our lifetimes.

Over the past 25 years there has been great improvement in the 5-year survival rate of major childhood cancers. The 5-year

CHAPTER 10 Environmental Health

survival rate for children for all cancer sites improved from 58% for those diagnosed between 1975 and 1977 to 81 % for children diagnosed between 1999 and 2007 (Jemal et al, 2010) . The list of possible causes of children's cancers includes the following: genetic abnormalities, ultraviolet and ionizing radiation, elec- tromagnetic fields, viral infections, certain medications, food additives, tobacco, alcohol, and industrial and agricultural chemicals (Ross and Olshan, 2004; Bassil et al, 2007). Clearly, the environment is playing an important role.

EVIDENCE-BASED PRACTICE Gilden et al examined the use of pesticides on ath letic fie lds where chi ldren play sports. Thi s cross-sectional descriptive study used a survey to assess playing field maintenance practices related to the use of pesticid es on the field. The authors ga ve the survey to 33 field managers in order to assess maintenance pra ctices. Their data were analyzed using descriptive statistics and generalized estimating equations

They found that 65.3 % of the manage rs sa id they applied pesticide s, primar- ily herbicides, to the fields. They also found tha t managers of urban and suburban fields were less likely to apply pesticides than we re managers of rural fields. The use of pesticides presents many health hazards, and the results of this study demonstrated that children who enga ge in spo rts activi- ties on athletic fields are exposed to health hazards. • Nurse Use: Nurses can inform people such as schoo l officials, coaches, and

field managers of the dangers of using pesticides on athletic fields.

Gi lden R, Friedmann E, Sattler B, et al: Potential health effects re lated to pesticide use on athletic fi elds. Public Hea lth Nursing 29(3) 198-207, May/June 2012.

Children are not just little adults. They are different in many ways, particularly with regard to their exposures and responses to the environment. As nurses, we know that infants and young children breathe more rapidly than adults, and this increase in respiratory rate translates to a proportionately greater exposure to air pollutants. While infants' lungs are developing they are particularly susceptible to environmental toxicants . Although full function of the lungs is attained at approximately age 6, changes continue to occur in the lungs through adolescence (Dietert et al, 2000) . Children are short and, as such, their breathing zones are lower than adults, causing them to have closer contact to the chemical and biological agents that accu- mulate on floors and carpeting. Children of color and poor children in America are disproportionately affected by a range of environmental health threats, including lead, air pollution, pesticides, incinerator emissions, and exposures from hazard- ous waste sites (Suk and Davis, 2008; Landrigan et al, 2010).

In clinical settings, there is little that can be done to address a child's body burden of toxic chemicals; however, the nursing community as a profession has a weighty obligation to under- stand the science and risks associated with environmental pol- lutants and to engage in the political and economic decisions regulating the environment that have a profound effect on human health, especially the health of our children. This engagement occurs in policy-making arenas including legisla- tive, regulatory, and international treaties. Nurses have increas- ingly become involved in the policy arena. The Alliance of Nurses for Healthy Environments is actively engaging nurses in

PART 3 Conceptual and Scientific Frameworks

state and federal chemical policies and energy policies (includ-

ing fracking) as they relate to health, and policies related to

sustainable foods. Children's bodies also operate differently. Some of the pro -

tective mechanisms that are well developed in adults, like the

blood-brain barrier, are immature in young children, thereby

increasing their vulnerability to the effects of toxic chemicals.

And finally, the kidneys of young children are less effective at

filtering out undesirable toxic chemicals, and these chemicals

then continue to circulate and accumulate. Infants and young children drink more fluids per body weight

than adults, thus increasing the dose of contaminants found in

their drinking water, milk (hormones and antibiotics), and juices

(particularly pesticides). If an adult were to drink a proportionate

amount of water to an infant, the adult would have to drink

about 50 glasses of water a day. Children also eat more per body

weight, eat different proportions of food, and absorb food differ-

ently than adults (EPA, 2013). How many adults could eat the

same amount of raisins pound-for-pound as the average 2-year-

old? Children consume much greater quantities of fruits and fruit

juices than adults, once again adding exposure to doses of pesti-

cide residues. The average 1-year-old drinks 21 times more apple

juice, 11 times more grape juice, and nearly 5 times more orange

juice per unit of body weight than the average adult (Rawn et al,

2004). The Food Quality Protection Act (FQPA) was passed to

specifically address the consumption patterns and special vulner-

abilities of children (Box 10-5).

BOX 10-5 Provisions Under the Food Quality Protection Act Regarding Pesticide Exposure to Children from Multiple Sources

New provisions under the Food Quality Protection Act of 1996 related to

protection of infants and children: Health-based standard: A new standard of a reasonable certainty of "no harm"

that prohibits taking into account economic considerations when children

are at risk. Additional margin of safety: Requires that the EPA use an additional 10-fold

margin of safety when there are adequate data to assess prenatal and

postnatal development risks.

Account for children's diet: Requires the use of age-appropriate estimates of

dietary consumption in establishing allowable levels of pesticides on food

to account for chi ldren's unique dietary patterns.

Account for all exposures.· In establishing acceptable levels of a pesticide on

food, the EPA must account for exposures that may occur through other

routes, such as drinking water and residential application of the pesticide.

Cumulative impact. The EPA must cons ider the cumulative impact of all pes-

ticides that may share a common mechanism of action.

Tolerance reassessments: All existing pesticide food standards must be reas-

sessed over a 10-year period to ensure that they meet the new standards

to protect children .

Endocrine disruption testing: The EPA must screen and test all pesticides and

pesticide ingredients for estrogen effects and other endocrine disruptor

activity. Registration renewal: Establishes a 15-year renewal process for all pesticides

to ensure that they have up-to-date science eva luations over time.

From Enviro nmental Protection Agency: Food Quality Protection Act

of 1996. Available at http://www.epa.gov/pesticides/regulation/laws/

fgpa/. Accessed Decemb er 15, 2010 .

Toxic chemicals can have different effects depending on the

timing of exposure. During fetal development, there are periods

of exquisite sensitivity to the effects of toxic chemicals. During

such times, even extraordinarily small exposures can prevent or

change a process that may permanently affect normal develop-

ment. The brain undergoes rapid structural and functional

changes during late pregnancy and in the neonatal period.

Therefore, it is extremely important to safeguard women's envi-

ronments when they are pregnant (Table 10-1).

Alarmingly, 27 states have issued mercury contamination

advisories for fish in every lake and river within their state's

borders (EPA, 2009). According to the EPA, more than 1 million

women in the United States of childbearing age eat sufficient

amounts of mercury-contaminated fish to risk damaging brain

development of their children. Nurses in all settings need to

understand the implications that the fish advisories have for

their clients and communities, and the contribution that the

health sector has in creating this health risk, while at the same

time counseling on the positive contribution of fish to a nutri-

tionally balanced diet. About 84,000 chemicals are used in commerce in the United

States (EPA, 2014). Almost all are man-made; 15,000 of them

are produced annually in quantities greater than 10,000 lb and

2800 of them are produced in quantities greater than 1 million

pounds per year (Goldman and Koduru, 2000). Of the 2,800,

only 7% have been tested for developmental effects and only

43% have been tested for any human health effects.

Companies are not required to divulge the results of their

private testing. A full battery of neurotoxicity tests is not

required even for pesticides that may be sprayed in nurseries

and labor and delivery areas, not to mention in homes. To make

things even more complicated, risks from multiple chemical

exposures are rarely considered when regulations are drafted.

Such an omission ignores the reality that both children and

adults are exposed to many toxic chemicals, often concurrently.

The only exception to this rule is in the case of regulations

regarding pesticides that are used on food (Figure 10-4). This

exception was created by the 1996 FQPA, in which Congress

acknowledged that children eat foods that may be contaminated

by more than one pesticide residue. See Box 10-5 for the provi-

sions under the FQPA.

PRECAUTIONARY PRINCIPLE

With thousands of chemical compounds now creating a chemi-

cal soup in our air and water (and in our bodies, in our breast

milk), it is increasingly difficult to prove specific hypotheses

regarding the relationship of exposure to a singular chemical

and disease outcome in humans. It has been suggested that we

adopt a precautionary approach when research and other indi-

cators demonstrate a possible toxic relationship between a

chemical and health. Box 10-6 presents the Wingspread State-

ment on the Precautionary Principle. This precautionary

approach calls for action to reduce potentially toxic exposure to

humans in light of data or other indicators, rather than delaying

until more "conclusive" studies are performed. We will never

have the perfect studies. Nurses, who are trained in disease

CHAPTER 10 Environmental Health

TABLE 10-1 Workplace Hazards to Women of Reproductive Age* Agent Observed Effects Potentially Exposed Workers

Cancer treatment drugs (e.g., methotrexate) Organic solvents (e.g., toluene, xylene,

formaldehyde)

Infertility, miscarriage, birth defects, low birth weight Miscarriage

Health care workers. pharmacists Health care workers. laboratory workers. print shop

and manufacturing employees Lead Infertility, miscarriage, low birth weight, developmental

disorders Battery makers, solderers, welders, bridge

repainters, firing range workers. home remodelers Many types of workers Miscarriage, preterm delivery Strenuous physical tabor (e.g., prolonged

standing, shift/night work) Cytomegalovirus Birth defects, low birth weight, developmental disorders Health care workers, workers who have contact

with infants and children Parvovirus 819 Miscarriage

Rubella Birth defects, low birth weight

Health care workers, workers who have contact with infants and children

Health care workers, workers in who have contact with infants and children

Toxoplasmosis Varicella zoster

Miscarriage, birth defects, developmental disorders Birth defects, low birth weight

Animal care workers, veterinarians Health care workers, workers who have contact

with infants and children

*Th is list is not comp lete . Info rmation about these hazards is constantly be ing revised. Readers should not assume that a substance is safe if it is missing from this list. Source: National Institute for Occupational Safety and Health (www.cdc.gov/niosh/99-104.html)

FIG 10-4 Aerial application of agricultural pesticides makes it very difficult to control exposures. The chemica ls get tracked into homes in farming communities. (Copyright© 2011 Photos. com, a division of Getty Images . Al l rights reserved. Photo #87531230.)

prevention, appreciate and should advocate for a precautionary approach when it may prevent injuries or illnesses. The ANA has adopted the precautionary principle as the basic tenet on which to guide its environmental advocacy work.

The bottom line is that life depends on the environment, and what humans do collectively can affect this vital resource for present and future generations. A central concept in Native American cultures is that humans are stewards, not proprietors, of the environment. Native Americans make the "Rule of Seven" central to all environmental decisions: What will be the effect

on the seventh generation? A quote (Myths -Dreams-Symbols, 2006) attributed to Chief Seattle, a nineteenth-century Native American, illustrates the need to think more holistically when we consider environmental impacts: "Whatever befalls the earth befalls the sons of the earth. Man did not weave the web of life; he is merely a strand in it. Whatever he does to the web, he does to himself." McDonough suggests that, as we make policies, plans, and designs, we ask ourselves how these decision are evidence that "we love all the children of all the species for all times" (Huff interview with McDonough, 2013).

Mary O'Brien, in her book Making Better Environmental Decisions: An Alternative to Risk Assessments, notes that we are repeatedly given a very short list of risk reduction choices, and that the public is not effectively engaged in the decision-making process. She suggests that a broader range of options would allow us to see the possibilities for further reducing ( or even eliminating) risks and that the process should be much more democratic in nature. O'Brien suggests the best approach to making effective environmental decisions is to use information, emotion, and a sense of relationship to others concurrently. By "others" she means other species, cultures, and generations (O'Brien, 2000). Her method is consistent with a nursing approach. Using her approach will require that nurses more actively engage in environmental health-assessing environ- mental health risks, developing risk reduction strategies, and supporting policies that embrace the precautionary principle and care for all of the children of all of the species for all times.

ENVIRONMENTAL HEALTH RISK REDUCTION Prevention is a core goal in every public health intervention. Preventing problems is less costly whether the cost is measured in resources consumed or in human health effects. Policies, as well as practices, can promote primary prevention. After we have assessed the environmental risks in our communities, we

' ;_ 232 PART 3 Conceptual and Scientific Frameworks

BOX 1 0-6 Wingspread Statement on the Precautionary Principle

In 1998 an international group of health and public hea lth professionals, scientists, government officials, la wyers, grassroots activists, and labor activ- ists met at a conference center called "Wingspread" in Wisconsin to define the "precautionary principle." The group issued the fol lowing consensus statement:

The relea se and use of toxic substances, the exploitation of resou rces, and physica l alterations of the environment have had substantia l unintend ed consequences affecting human health and the environment. Some of these concerns are high rates of learning deficiencies, asthma, cancer, birth defects and species extinct ions, along with globa l climate change, stratospheric ozone depletion and worldwide contamination with toxic substances and nuclear materials.

We believe existing environmental regulations and other decisions, par- ticularly those based on risk assessment, have failed to protect ade- quately human health and the environment the larger system of which humans are but a part.

We believe there is compelling evidence that damage to humans and the worldwide environment is of such magnitude and seriousness that new principles for conducting human activities are necessary.

While we realize that human activities may involve hazards, people must proceed more carefully than has been the case in recent history Corpo- rations, government entities, organizations, communities, scientists and other individuals must adopt a precautionary approach to all human endeavors.

Therefore , it is necessary to implement the Precautionary Principle: When an activity raises threats of harm to human health or the env ironment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically. In this context the proponent of an activity, rather than the public, shou ld bear the burden of proof.

The process of applying the Precautionary Principle must be open, informed and democratic and must include potent ially affected parties. It must also involve an examination of the full range of alternatives, including no action.

Wingspread Statement on the Preca utionary Princ iple, Rac ine WI, 1998. Availab le at http://www.gdrc.org/u-gov/precaution-3.html. Retrreved March 12, 2015.

can apply the basic principles of disease prevention when plan- ning intervention strategies, For lead exposure, remediating a home with lead-based paint to make it lead safe applies the primary prevention strategy of removing the exposure ( at least from that specific source oflead) (Figure 10-5). Even good lead poisoning surveillance will not prevent lead exposure, but may help with early detection of rising blood lead levels. Such sur- veillance is a secondary prevention strategy. Finally, when a symptomatic child is seen, it is important to have a health care system readily available in which specialists familiar with lead poisoning will provide swift medical interventions to reduce blood lead levels, thus reducing the risk of further harm. This is a tertiary prevention response. Box 10-7 presents examples of risk reduction strategies for nurses in the health care setting.

Industrial Hygiene Hierarchy of Controls For workplace exposures, industrial hygienists have developed a "hierarchy of control" for avoiding or minimizing employee

FIG 10-5 Lead can be found in many places in a home. Nurses shou ld help fami lies learn about these sources and t ake actions to remove any lead-based paint using certified professionals. Good hygiene is key to reducing lead dust exposure, especially given that urban soot wil l often have lead from the legacy of lead used in gasoline for many decades. (From U.S. Environ- mental Protection Agency. Available at http://www. epa.gov/ lead/pubs/ leadpdfe.pdf Accessed December 29, 2010.)

exposures to potentially hazardous chemicals. Industrial hygien- ists are public health professionals who specialize in workplace exposures to hazards- physical, chemical, and biological-that create the conditions for health risks (Box 10-8 presents the industrial hygiene hierarchy of controls). Once it is estab - lished that a human health threat exists, develop a plan of action- a way of eliminating or managing (reducing) the risk. Risk management should be informed by the risk assessment process and involves the selection and implementation of a strategy to eliminate or reduce risks.

Box 10-9 lists the 3 Rs for reducing environmental pollution.

Nursing interventions to reduce environmental health risks can take many forms. Education is one example of a nursing intervention. By working with a wide array of community

BOX 1 0-7 Risk Reduction: Every Nurse's Role

In the health care setting (hospital, clinic, home health). we have many oppor- tunities to make environmentally friend ly and healthy choices: • Shift to electronic records, thus avoiding the use of paper. When paper is

a must, use products that are made from recyc led ingredients • Recycle: paper, glass, cans, plastic, small batteries, blue wrap, electronic

equipment • Work with suppliers to get products with minimum packaging and the

safest ingredients possible: "environmentally preferable purchasing"

• Promote the use of green cleaners • Go fragrance free by using fragrance-free products in the hospital and

creating a policy that requires employees to use fragrance-free personal care products (shampoos, creams, etc.)

• Turn off lights AND computers AND patient monitoring equipment when rooms are not being used

• Report leaky sinks, toilets, and other plumbing sources • Promote the purchase of local, sustainably grown foods (with a preference

for organic, no use of GMOs, no use of unnecessary antibiotics, and no pesticides)

• Start a hospital/clinic/health department garden • Start a Green Team, or join the existing one in your institution • Create community while doing these activities and build re lationships-it

makes the whole process more meaningful and fun!

BOX 1 0 - 8 Industrial Hygiene Hierarchy of Controls*

Eliminate unnecessary toxic chemicals. Substitute less hazardous or nonhazardous substances (e.g., using water-

based vs. so lvent-based products). Isolate the hazardous chemicals from human exposure (e.g., use closed

systems). Apply eng inee ring controls (e.g ., ventilation systems, including exhaust

hoods). Reduce the exposures through administrative controls (e.g., rotating

employees in areas with high exposures). Use personal protective equipment (e.g., gloves, respirators, protective

clothing).

*In add ition, education is a critical too l in the hierarchy of cont rols. Modified from Levy B, Wegman D: Occupationa l hea lth: recogn izing and preventing wo rk-related disease and injury, ed 4, Ph iladelph ia, 2000, Lippincott Williams & Wi lkins.

BOX 1 0-9 The 3 Rs for Reducing Environmental Pollution

The "3 Rs" adage of the environmentalist community-reduce, reuse, and recycle-helps us consider ways to decrease our personal impact on the environment, and thereby decrease environmental health risks. These con- cepts can apply to our health care settings, as well as our homes. By recycling, we prevent the need to extract more resources from the earth to manufacture products. By recycling, we also prevent products from unnecessary landfilling or incineration. Choosing reusable products, versus sing le-use devices and products, similarly prevents the need for manufacturing more products and decreases the waste stream. Reducing our waste stream can also be accom- plished generally by a reduction in consumption (buying less "stuff," as well as by reduc ing unnecessary packaging and other nonessential goods). The "Story of Stuff" (www.thestoryofstuff.org) provides an excellent overview of the "cradle to grave" travels of products and the full range of their human and eco logical impacts.

CHAPTER 10 Environmental Health

members, nurses can help a community understand the rela- tionship between harmful environmental exposures and human health and guide the community toward risk reduction on the basis of both individual behavior changes, as well as community- wide approaches. In communities in which radon is likely to be a naturally occurring exposure, nurses can educate the com- munity about the health risks, methods to measure radon levels in a home, and how to address unhealthy radon levels.

Nurses work with individuals, families, and communities in all three levels of prevention. For example, in Planned Parent- hood Clinics in the United States, as a form of primary preven- tion, clinicians ask clients about possible environmental health risks in their everyday lives and then direct them to safer prod- ucts and healthier behaviors to decrease potentially toxic expo- sures. Secondary prevention takes place when pediatric clinics include lead screening as part of their protocols. By doing so they are apt to find children with elevated blood lead levels, which then allow them to act to decrease the child's environ- mental lead exposures. This form of secondary prevention does not actually prevent the exposure but calls for action based on evidence of exposure. If a child has a seriously high blood lead level, the child would be admitted to the hospital for chelation therapy which is a process used to decrease the body's burden of lead.

• LEVELS OF PREVENTION Example Applied to lead-Based Paint Exp osure

Primary Prevention Eliminate lead-based paint and lead-based paint dust from the home.

Secondary Prevention Provide blood lead testing of children in communities with older housing stock.

Tertiary Prevention When a child presents with extremely elevated blood lead leve ls, make sure the child is being cared for by a health professional who is familiar with cl ini- cal interventions to reduce blood lead levels using clinical (chelating medica- tions) interventions, while concurrently assuring that the child returns to a lead-safe place,

The clinical intervention is tertiary prevention. It neither prevents the expo- sure, nor focuses on decreasing the exposure, but rather focuses on decreas- ing the potential hea lth sequela associated with elevated lead levels.

Risk Communication Risk communication is both an area of practice and a skill that is a composite of two separate words: "risk" and "communica- tion ." Risk is a familiar term in nursing practice. It is understood in the health context when we counsel patients about the risks of pregnancy, communicable disease ( especially sexually trans- mitted disease), unintentional injury, and risk associated with personal choices ( e.g., smoking, alcohol consumption, and diet). Risk assessment in environmental health focuses on char- acterizing the hazard (the "source"), its physical and chemical properties, its toxicity, and the potential exposure pathways- mode of transmission, route of exposure, receptor population, and dose. In their seminal work on risk communication,

PART 3 Conceptual and Scientific Frameworks

BOX 1 0-1 o Definitions of Risk Risk has traditionally been defined by the following equation:

Risk= magnitude x probability

The re is a growing body of literature from practitioners and researchers who have studied the human reaction to risk-real and perceived. Sandman et al (1991) we re the first to examine the "outrage" factor that can influence the way in which we perceive ris k, particularly to environmenta l risks.

Risk= hazard+ outrage

Addressing only the hazard is doing only half of the necessary work; address ing the response (outrage) is equally important.

From Sandman PM, Chess C, Hane BJ: Improving dialogue with communities, New Brunswick, NJ, 1991 , Rutgers University.

BOX 10-11 Outrage Factors: Characteristics of Risk That Contribute to the Public's Feeling of Outrage

Safer = Less Outrage Less Safe = More Outrage

12 Principal Outrage Components Voluntary In vo luntary (coerced) Natural Industrial (artificial) Familiar Exotic Not memorable Memorable

Not dreaded Dreaded Chronic Knowable (detectable) Indi vi dually controlled Fair Morally irrelevant Trustworthy sources Responsive process

Catastrophic Unknowa ble (undetectable) Controlled by others Unfair Morally relevant Unt rustworthy sources Unresponsive process

Sandman, Chess, and Hane (1991) noted that risk has tradition-

ally been formulated as magnitude (the size, severity, extent of

area, or population affected) multiplied by the probability (how

likely exposure or damage is to occur) (Box 10-10). For example,

an environmental risk assessment of a contaminated site would

involve a calculation of the dose that might be received through

all routes of exposure, the toxicity of the chemical, the size and

vulnerability (age, health) of the population potentially exposed

(resident, future resident, transient), and the likelihood of expo-

sure. Sandman et al ( 1991) also noted that the reaction to things

that scare people and the things that kill people are often not

related to the actual hazard. They have gone further to probe

what is behind those differences and identified a list of"outrage

factors" to explain people's responses to risk (Box 10-11). They

maintain that the outrage is just as predictable and open to

intervention as the science of addressing the hazard.

"Communication" of risk involves understanding the outrage

factors relevant to the risk being addressed so they can be incor-

porated in the message-the information-either to create

action to ensure safety or prevent harm or to reduce unneces-

sary fear. An example of raising outrage to produce action can

be seen in the shift from emphasis on smokers (voluntary) to

victims of passive smoking (involuntary) to stimulate public

policy that limits or bans smoking in public places. When the

emphasis on risk went from a voluntary choice of smokers to

an involuntary exposure of nonsmokers, the outrage level of the

nonsmoking public became high enough to result in legislation

guaranteeing smoke-free public spaces ( e.g., public buildings,

airplanes, and restaurants). On the other hand, outrage decreases when people receive

information on the situation from a trusted source, and physi-

cians and nurses are often cited in surveys as trusted sources of

information on environmental risks (Kaiser Foundation, 2013).

The public trust is a compelling incentive to match professional

knowledge and skills to a community's expectations. The

outrage factor can also be a driving force in building credibility

and trustworthiness in every person whose work involves inter-

acting with the public. Risk communication includes all the principles of good

communication in general. It is a combination of the following:

• The right information: Accurate, relevant, in a language that audiences can understand. A good risk assessment is essen-

tial information for shaping the message.

To the right people: Those affected and those who are worried but may not be affected. Information on the community

is essential: geographic boundaries, who lives there (i.e.,

demographics), how they obtain information (e.g., flyers or

newspapers, radio, television, word of mouth), where they

congregate ( e.g., school, church, community center), and who

within the community can help plan the communication.

• At the right time: For timely action or to allay fear.

GOVERNMENTAL ENVIRONMENTAL PROTECTION -------------------- --- - The government has a variety of tools to address environmental

exposures. In addition to passing legislation, creating and

enforcing standards and regulations, deciding how land should

be used, providing permits, and supporting research, the gov-

ernment is actively engaged in educating the public. Many

federal agencies are involved in environmental health regula-

tion, such as the EPA, the FDA, and the Department of Agricul-

ture. The Department of Health and Human Services (DHHS)

has two major research institutes, the National Institute of

Environmental Health Science (NIEHS) and the National Insti-

tute of Occupational Safety and Health (NIOSH). Within

DHHS is the CDC (which includes the National Center for

Environmental Health [NCEH) that is responsible for tracking

environmental health trends, recommending clinical and public

health practices, and also engaging in research). Every state has

an agency responsible for environmental quality. At the city or

county level, the local health department most often manages

environmental health issues. However, environmental protec-

tion issues are typically directed by the state using both federal

and state laws. Box 10-12 lists key environmental protection

laws.

Potentially harmful pollution that cannot be prevented must

be controlled. An important step in the process of controlling

pollution is permitting, a process by which the government

BOX 10-12 Environmental Laws

National Environmental Policy Act (NEPA) The NEPA established the Environmental Protection Agency (EPA) and a national policy for the environment and provides for the establishment of a Council on Environme nta l Policy. All policies. regu lations. and publi c laws shall be inter- preted and administered in accordance wi th the policies set forth in this act.

Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) FIFRA provides federal control of pesticide distribution, sale, and use. The EPA was given the authority to study the consequences of pesticide usage and

requires users such as fa rme rs and utility compan ies to register when usi ng pesticides. Later amendments to the law requ ired applicators to take certifica- tion examinations. registration of all pesticides used in the United States, and proper labeling of pesticides that. if in accordance with specifications, will cause no harm to the environment (summary from FIFRA. 1972).

Clean Water Act (CWA) The CWA sets basic structure for regulating pollutants to U.S. waters. The law gave the EPA the authority to set effluent standards on an industry basis and continued the requirements to set water quality standards for all contam in ants in surface wa ter. The 1977 amendments fo cused on toxic pollutants. In 1987 the CWA was reauthoriz ed, and aga in focuse d on toxic pollutants, authorized citizen suit provisions, and funded sewage treatment plants.

Clean Air Act (CAA) The Clean Air Act regulates air em issions from aeria l, stationary, and mob il e sources . The EPA was authorized to establish National Ambient Air Quality Standa rds (NAAQS) to protect public health and the environment. The goal was to set and achieve the NAAQS by 1975. The law was amended in 1977 when many areas of the country failed to meet the standards. The 1990 amendments to the Clean Air Act intended to meet unaddressed or insufficiently addressed problems such as ac id ra in, ground level ozone, stratospheric ozone depletion, and air tox ics. Also in the 1990 reauthorization was a mandate for Chemical Risk Management Plans. This mandate requires industry to identify "worst case scenarios" regard ing the hazardous chem ica ls that they transport, use, or discard (summary from Clean Air Act, 1970).

Occupational Safety and Health Act (OSHA) The OSHA was passed to ensure worker and workplace safety. The goal was to make sure employers provide an emp loyment place free of hazard s to health and safety such as chem ica ls, excessive noise, mechanical dangers, heat or cold extremes, or unsanitary conditions. To estab li sh standards for the workplace. the Act also created NIOSH (National Institute for Occupational Safety and Health) as the resea rch institution for OSHA.

Safe Drinking Water Act (SOWA) The SOWA was estab lished to protect the quality of drinking water in the United States. The Act authorized the EPA to establish safe standards of purity and required all owne rs or operators of public water systems to comply with primary (h ea lth-related) standards.

Resource Conservation and Recovery Act (RCRA) The RCRA gave the EPA the authority to control the generation, tra nsportation, treatment. storage, and disposal of hazardous waste. The RCRA also proposed a framework to manage nonhazardous waste. The 1984 Federal Hazardous and So li d Waste Amendments to this Act requ ired phasing out land disposal of hazardous waste. The 1986 amendments enab led the EPA to address problems from underground ta nks storing petro leum and other haza rdou s substances.

Toxic Substances Control Act (TSCA) The TSCA gives the EPA the ability to track the 75,000 industrial chemicals currently produced in or imported into the United States. The EPA can req ui re

CHAPTER 10 Environmental Health

reporting or testing of chem ica ls that may pose environmental health risks and

can ban the manufacture and import of those chemicals that pose an unreason- able ri sk . TSCA supplements the Clean Air Act and the Toxic Release Invento ry.

Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA or Superfund) This law created a tax on the chemical and petroleum industries and provided

broad federal authority to respond directly to releases or threatened releases of

hazardous substan ces th at may endanger pu blic heal th or the environmen t.

Superfund Amendments and Reauthorization Act (SARA) SARA amended the Comprehensive Environmental Response, Compensation, and Liability Act with severa l changes and additions. The se changes inc lu ded increased size of the trust fund; encouragement of greater citizen participation in decision making on how si tes shoul d be cleaned up; increased state involve- ment in every phase of the Superfund program; increased focus on human health problems related to hazardous waste sites; new enforcement authorities and settlement too ls; emphasis on the importance of permanent remedies and inno- vative treatment technol ogies in clean-up of hazardous waste sites; and Super- fund actions to cons ider standa rd s in other federal and state regulat ions. (Under Superfund legis lation, the Federal Agency for Toxic Substances and Disease Reg istry was established.)

Emergency Planning and Community Right to Know Act (EPCRA) The EPCRA, also known as Ti tle Ill of SARA. was enacted to help local communi- ties protect pub lic health safety and the environment from chemical hazards. Each state was requi red to appo int a State Emergency Re sponse Commission that was required to divide their state into Emergency Planning Districts and establ ish a Local Emergency Planning Committee (L EPC ) for each district.

National Environmental Education Act The National Environmental Ed ucation Act created a new and better coordinated environm ental educati on emphasis at the EPA. It created the National Environ- mental Education and Training Foundation.

Pollution Prevention Act (PPA) Th e PPA focused ind ustry, government, and publ ic attention on reduction of the amo unt of pollution through cost-effective changes in production, ope rat ion, and use of raw materials. Pollution prevention also includes other pract ices that increase efficient use of energy, water, and other water resources, such as recyc ling, source reduction, and sustainable agricu lture.

Food Quality Protection Act (FOPA) The FQPA amended the Federal Insectic ide, Fungicide, and Rodentic ide Act and the Federal Food, Drug, and Cosmetic Act. The Act changed the way the EPA regulates pest ic ides. The requirements included a new safety standard of rea- sonab le certainty of no harm to be app li ed to all pesticides used on foods.

Chemical Safety Information, Site Security, and Fuels Regulatory Act (Amendment to Section 112 of Clean Air Act) This act removed from coverage by the Risk Management Plan (RMP) any flam - mable fuel when used as fuel or held for sale as fuel by a retail facility (flam- mable fuels used as a feedstock or he ld for sale as a fuel at a who lesa le facility are still covered). This Act req uired certain facilities to have in place a risk management program and submit a summary of that program, ca ll ed a Risk Management Plan (RMP) to the EPA. The law has two distinct parts that pertain to: flammable fuels and public access to Off-Site Consequence Analysis (OCA) data. OCA is "worst-case scenario" data.

PART 3 Conceptual and Scientific Frameworks

places limits on the amount of pollution emitted into the air or water. A permit is a legally binding document.

Environmental standards may describe a permitted level of emissions, a maximum contaminant level (MCL), an action level for environmental clean-up, or a risk-based calculation; environmental standards are required to address health risks. It is the responsibility of potential polluters to operate within the regulations and standards. Compliance and enforcement are the next building blocks in controlling pollution. Compliance refers to the processes for ensuring that permit/standard/regu- latory requirements are met. Clean-up or remediation of envi-

ronmental damage is another control step. Public information and involvement processes, such as citizen advisory panels or community forums, are integral to the development of stan- dards, on-going monitoring, and remediation.

POLICY AND ADVOCACY There are almost 3 million nurses in the United States today-

approximately 1 in every 100 Americans is a registered nurse!

Nurses can and should be a strong voice for a healthy environ- ment. As informed citizens, nurses can take a variety of actions to protect the environmental health of families, clients, and communities. Nurses are perceived as trusted messengers and

as reliable sources of environmental health information and as

such, have a responsibility to be informed and take action in

the best interest of public health. Often, legislators are called to

vote on environmental legislation without a sound understand-

ing of how the legislation may affect public health . Nurses can

serve as a resource for state and federal legislators and their staff.

Although every nurse may not be an expert in all aspects of

environmental health, every nurse does have a basic education

in human h ealth and has a sufficient understanding of who may

be most vulnerable to environmental insult. Nurses' thoughts

about the potential impacts of new laws on the health of indi-

viduals and communities are valuable to legislators and other

policy makers, as well as the public. Grounded in science and using sound risk communication

skills, nurses become the most credible sources of information

at community gatherings, formal governmental hearings, and

professional nursing forums. Nurses work as advocates for envi-

ronmental justice so that all members of the community have

a right to live and work in an environment that is healthy and safe (Mood, 2002). Public health nurses also volunteer to serve

on state, local, or federal commissions, and they know about

zoning and permit laws that regulate the impact of industry and

land use on the community. Many nurse legislators began their

careers by advocating for the rights of others. Nurses must read,

listen, and ask questions. Then, as informed citizens, they will

be leaders, fostering community action to address environmen-

tal health threats. In 2008 the Alliance of Nurses for Healthy Environments was

created to coalesce individual nurses and nursing organizations

around issues associated with the environmental exposures and

human health. This organization addresses the integration of

environmental health into nursing education, practice (includ- ing greening the health care sector), research, and advocacy.

Environmental Justice and Environmental Health Disparities Some diseases differentially affect different populations. Certain environmental health risks disproportionately affect poor people and people of color in the United States. If you are a poor person of color, you are more likely to live near a hazard- ous waste site or an incinerator, and more likely to have children who are lead poisoned. You are also more likely to have children with asthma, which has a strong association with environmen- tal exposures. Campaigns to improve the unequal burden of environmental risks in communities of color and in poor com- munities are striving to achieve environmental justice or envi- ronmental equity.

In 1993 the Environmental Justice Act was passed, and in 1994 Executive Order 12898, "Federal Actions to Address Envi- ronmental Justice in Minority Populations," was signed. This Act and the subsequent actions created policies to more com- prehensively reduce the incidence of environmental injustice by mandating that every federal agency act in a manner to address

and prevent illnesses and injuries. Nursing interventions and

involvement in environmental health policies can have a signifi- cant effect on the health disparities experienced by our most challenged communities.

Environmental Health Threats from the Health Care Industry: New Opportunities for Advocacy Many choices in the health care setting affect environmental

health. Nurses often lead in reducing the use of mercury-

containing products in hospitals. The use of mercury-containing

thermometers and sphygmomanometers leads to a risk of

breakage, which releases a highly toxic substance into the work-

place. Further, when a hospital uses incineration to dispose of

their waste, the mercury-containing products will create signifi-

cant releases of mercury into the air, thus contaminating com-

munities. This airborne mercury will be present in raindrops;

when the airborne mercury lands on water bodies ( e.g., lakes,

rivers, or oceans), it is converted by the microorganisms in the

water to methylmercury, which is highly toxic to humans. The

methylmercury is then bioaccumulated in the fish: as larger fish eat smaller fish, the body burden of methylmercury increases

significantly. Many synthetic chemicals that contaminate the environment

are referred to as persistent bioaccumulative toxins (PBTs) or persistent organic pollutants (POPs ). These are chemicals that do not break down in air, water, or soil, or in the plant, animal,

and human bodies to which they may be passed. Ultimately,

since humans are at the top of the food chain, these chemicals

may come to reside in our bodies. For instance, lead, which

should not be found in the human body, can be found in the

long bones of almost any human in the world because of its

ubiquitous use and presence in our environment.

Dioxin, another pollutant that contaminates our communi-

ties, is created, in part, by the health care industry. Dioxins are

created when we manufacture or burn (incinerate) products

that contain chlorine, such as bleached white paper or polyvinyl chloride (PVC) plastics. When dioxins are released into the

environment, they are consumed by agricultural animals (e.g., beef and dairy cows, hogs, and poultry) and fish, where they are stored in fat cells as they work their way up the food chain. This phenomenon has resulted in dioxin deposition in breast tissue and been found in both cow and human milk. Virtually all women now have dioxin in their . breast tissue. Dioxin, an endocrine-disrupting chemical and a strong carcinogen, is asso- ciated with several neurodevelopmental problems including learning disabilities and is now in every human's body. The solution to this problem is to stop releasing dioxins into the environment. In the health care setting, one way to eliminate the creation and release of dioxins is to stop using products like PVC plastics and selecting safer alternatives by employing envi- ronmentally preferable purchasing policies and practices.

An international campaign called Health Care Without Harm is working to reduce and eliminate mercury and PVC plastic in the health care industry, as well as the elimination of incineration of medical waste. The ANA was a founding member of the Health Care Without Harm campaign, and nurses have taken many leadership roles in the activities in the United States and around the world. The Health Care Without Harm website (http://www.noharm.org) provides outstanding information on greening hospitals and resources about pollution prevention in the health care sector.

REFERRAL RESOURCES There is no one source of information about environmental health nor is there a single resource to which a public health nurse can refer an individual or community should an environ - mentally related problem be suspected. As mentioned earlier, the NLM's ToxTown is a great starting place, and it allows the interested browser to dig deeply into environmental health content. TOXNET has an amalgamation of important databases and environmental health literature and additional peer- reviewed environmental health literature. The EPA is another rich source of information (www.epa.gov). Use of the Internet

CHAPTER 10 Environmental Health

makes information widely accessible, but finding an actual person to assist you or the communities you serve may not be as easy. One starting point may be the environmental epidemi- ology unit or toxicology unit of the state health department or department of environmental quality. The Association of Occu- pational and Environmental Clinics (AOEC) (http://www.aoec .org) is a national network of specialty clinics and individual practitioners available for consultation and sometimes for pro- vision of educational programs for health professionals. Through AOEC, you can also find the Pediatric Environmental Health Specialty Units; there are 10 throughout the country. These specialty units were specifically established to provide consultation on environmental health issues. Another local or state resource may be environmental health experts in nursing or medical schools or schools of public health.

Local resources include local health and environmental pro- tection agencies; poison control centers; agricultural extension offices; and occupational and environmental departments in schools of medicine, nursing, and public health. Some local and state agencies have developed topical directories to assist in accessing the appropriate staff for specific questions. Many of the resources have websites that allow ready access through the Internet and can be located by using any of the popular search methods. Box 10-13 presents an extensive list of environmental health agency resources.

The most active advocates for environmental health policies are grassroots organizations, the big environmentalist organiza- tions, and environmental justice organizations. To learn more about who these organizations are, see the Resource Section under nongovernmental organizations.

ROLES FOR NURSES IN ENVIRONMENTAL HEALTH Nurses can be involved in many environmental health roles, in full-time work, as an adjunct to existing roles, and as informed citizens. Nurses who are passionate about this issue can develop

BOX 1 0 -1 3 Information and Guidance Sources for Referra ls The websites for each of these agencies can be accessed directly through the Weblinks feature on the book's webs ite at http://evolve.e lsevier.com/ Stanhope.

Federal Agencies Agency for Toxic Substances and Disease Registry Centers for Disease Control and Prevention Consumer Product Safety Commission Envi ronmental Protection Agency Office of Children's Environmental Hea lth Food and Drug Administration National Institute for Occupational Safety and Health National Institute of Environmenta l Health Sciences National Institutes of Health National Cancer Institute National Institute of Nursing Research Occupational Safety and Health Administration National Library of Medicine-TOXNET

State Agencies State Health Departments State Environmental Protection Agencies

Associations and Organizations American Ass ociation of Poison Control Centers American Association of Occupational Health Nurses Association of Occupational and Environmental Clinics Beyond Pesticides Center for Health and Environmental Justice Children's Environmental Health Network Environm ental Defense Environmental Working Group Health Care Without Harm National Environmental Education Foundation Natural Resources Defense Council Pediatric Environmental Hea lth Specialty Units Society for Occupational and Environmental Health

PART 3 Conceptual and Scientific Frameworks

research expertise, sit on commissions, write articles, and take

national leadership roles. All nurses can include environmental

exposures in their history taking; consider the environmental

impacts of the products they select for their clinics, hospitals,

schools, and other settings; promote recycling and reuse of

products; and promote environmentally preferable purchasing.

Each type and level of engagement is important. The following

are some ways in which nurses can get involved both profes-

sionally and as informed citizens:

• Community involvement/public participation. Organizing,

facilitating, and moderating; making public notices effective

and public forums accessible; welcoming input. Making

information exchange understandable and problem solving

acceptable to culturally diverse communities are valuable

assets a nurse contributes. Skills in community organizing

and mobilizing can be essential for a community to have a

meaningful voice in decisions that affect them.

Individual and population risk assessment. Using nursing

assessment skills to detect potential and actual exposure

pathways and outcomes for clients cared for in the acute,

chronic, and healthy communities of practice.

• Risk communication. Interpreting, applying principles to

practice. Nurses may serve as skilled risk communicators

within agencies, working for industries or working as inde-

pendent practitioners. Amendments to the Clean Air Act

require major industrial sources of air emissions to have risk

management plans and to inform their neighbors of specifics

of the risks and plans (Clean Air Act, 1996).

• Epidemiologic investigations. Nurses need to have the skills to

respond in scientifically sound and humanely sensitive ways

to community concerns about cancer, birth defects, and still-

births when citizens fear environmental causation.

• Policy development. Proposing, informing, and monitoring

action from agencies, communities, and organization

perspectives. The assimilation of the concepts of environmental health

into a nurse's daily practice gives new life to traditional public

health values of prevention, community building, and social

justice. Box 10-14 presents the work of three nurses currently

working in environmental health.

As nurses learn more about the environment, opportunities

for integration into their practice, education programs, research,

advocacy, and policy work will become evident and will evolve.

Opportunities abound for those pioneering spirits within the

nursing profession who are dedicated to creating healthier envi-

ronments for their clients and communities.

BOX 1 0-1 4 Examples of Three Modern-Day Environmental Health Nu rsing Pioneers

In Baltimore, MO, Dr. Claudia Smith (a nurse who is on the faculty at the

University of Maryland) directed a project in which nurses worked with com-

munity members to address a variety of hea lth problems associated with poor

housing conditions. For this project, which was funded by the U.S. Department

of Housing and Urban Development. Dr. Smith hired and trained community

members to assess and reduce un healthy conditions caused by lead-based paint.

high leve ls of carbon monoxide, and asthma triggers (e g., dust mites, pet

dander, and pests); she taught commun ity members about safer choices for pest

control using the least toxic approach to pest management by using an inte-

grated pest management approach.

After Denise Choiniere, a graduate student in community health who was

working in the cardiac care unit (CCU) at the University of Maryland Medical

Center, learned about the health effects associated with heavy metals, she was

very uncomfortable with simply throwing away the batteries that were used in

the many small devices, such as Holter monitors. Instead, she deve loped a

battery recycling program for the CCU and the telemetry unit She then discov-

ered that her hospital purchased 97,000 small batteries every yea r. Each of these

small batteries contains a heavy metal-mercury, lithium. cadm ium, or lead.

She was the driving force in developing a hospital-wide, small battery recycling

program This activity created a whole new career tra jectory for Ms. Choiniere,

who was recently appo inted to the executive position of Sustainabi lity Coordina-

tor for the whole hospital. She has since addressed green cleaning products,

promoted the recycling of "blue wrap" used in the operating rooms. and orga-

nized a farmers' market that meets weekly in front of the hospital, thus bringing

locally grown and sustainably farmed products to hospital employees and the

surrounding community. She then was given oversight for all of the 650-bed

hospital's purchases.

Dr. Robyn Gilden is a nursing faculty member who worked for 5 years with

communities that knew or suspected that they were living near a hazardous

waste site. She learned about the many laws and agencies involved in hazardous

waste site assessments and clean-ups. Hazardous wastes can affect soil. water.

and air. Sources of contamination may come from old, unlined landfills; uncon-

trolled dump sites; spills or discharges from industry; leaking underground

storage tanks (like gasoline tanks); or runoff from fields. The Agency for Toxic

Substances and Disease Registry (ATSDR), a federal agency responsible for

documenting the health hazards associated with environmental exposures,

maintains a listing of the most problematic contaminants found at polluted sites.

They include a wide range of highly toxic chemicals including arsenic, lead,

mercury, vinyl chloride, benzene, polychlorinated biphenyls (PCBs), and cadmium.

These toxic chemicals top the lrst because they are the most commonly found

contaminants and pose a significant threat to human health based on routes of

exposure and leve l of toxicity. Dr. Gilden learned about the resources that are

avai lable for the best and most current toxicological information. The National

Library of Medicine's TOXNET and ATSDR's websites, including the ir ToxFAQs,

are some of the best sources of navigable information.

In work ing with communities. Dr. Gilden met with government officials, includ-

ing mayors of small towns, as we ll as concerned parents, people from local

governments, health departments. educational institutions, businesses, deve l-

opers, bankers, realtors, and other community members. She has also learned

about the many statutes that cover hazardous waste sites, such as the Super-

fund legislation (which covers the most polluted waste sites) and Brownfields

legislation (which covers contaminated sites where economic development is

involved). Both these pieces of legislation mandate community involvement,

which is where Or. Gilden's community health and risk communication skills are

used. Regardless of who is responsible for or in charge of a contaminated site,

the nurse understands that the community must be an active and equal partici-

pant. It is the community members who will be impacted by decisions and have

to live with the results of clean-up and redevelopment. As is true of most nurses,

Dr. Gilden quickly became a trusted person to the community members.

When she discovered the "Pesticide Warning" signs on the playing fields

where her children played sports, this launched Dr. Gilden into a new area of

research and advocacy regarding children's exposures.

I PRACTICE APPLICATION Following are two case scenarios related to exposure pathways. The first involves lead poisoning and the second, fracking- related concerns.

At the county health department, a 3-year-old boy named Billy presents with gastric upset and behavioral changes. These symptoms have persisted for several weeks. During your history taking, you discover that Billy's parents have been renovating their old home. A parent in Billy's daycare center suggested that Billy's symptoms might be associated with lead, so Billy's parents have brought him in to the clinic.

You relay this information to the primary care practitioner who, in turn, orders a blood lead level, which comes back at 45 mcg/dL. This is a very high value.

You research lead poisoning and discover that there are many potential health effects of lead exposure and that children are at greatest risk because their bodies, especially their nervous systems, are still developing. You also find that chronic lead poisoning may lead to long-term effects, such as developmental delays and impaired learning ability.

You let the health professional know about the lead poison- ing specialists in the nearby children's hospital. On further investigation, you find that Billy's home was built before 1950 and is still under renovation. Billy should not return to the home. At this point, the sanitarian from the local health depart- ment tests the dust in the home and finds high lead levels. Because of Billy's age and associated behaviors, such as

I KEY POINTS Nurses need to be informed professionals and advocates for citizens in their community regarding environmental health issues.

• Models describing the determinants of health acknowledge the role of the environment in health and disease.

• Climate change is creating profound risks to human health globally and in the United States. For most chemicals in our homes, work, schools, and com- munities, no research has been completed to determine whether or not they will cause health effects.

• Prevention activities include education, reduction/elimina- tion of exposures, waste minimization, energy policies, and land use planning. Pollution control activities include use of technologies; environmental permitting; environmental standards, moni- toring, compliance, and enforcement; and clean-up and remediation.

• Each nursing assessment should include questions and observations concerning potential and existing environmen- tal exposures.

CHAPTER 10 Environmental Health

hand-to-mouth activities, you determine that the lead dust in the home is the probable exposure. However, you must also consider multiple sources of exposure. 1. What other sources of exposure might exist? 2. What would you include in an assessment of this

situation? 3. What prevention strategies would you use to resolve this

issue? At the individual level? At the population level? Mrs. Bell calls the local health department to report that her

drinking water, from their private well, is discolored and that her son has been experiencing headaches and nose bleeds. You talk with Dan, the health department's environmental health professional (sanitarian) who tells you that there is new "frack- ing" activity on the east side of your rural county, where Mrs. Bell and her family live, and that this may be the reason for the water discoloration and the child's symptoms. You look up "£racking" and discover that the word is shorthand for hydraulic fracturing, a new technique for extracting natural gas that is fraught with community and health concerns. (For more infor- mation on fracking, see the Resource Section.) Dan and you agree to make a site visit to the Bell's farm. 1. What will you be looking for on your visit? 2. How can you help the Bells, if any of their issues seem to be

associated with the nearby £racking site? 3. What other experts are available to you and the Bells?

Answers can be found on the Evolve site.

• Useful environmental exposure data are difficult to acquire. Those data that exist can be used to aid in the assessment, diagnosis, intervention, and evaluation of environmentally related health problems.

• Both case advocacy and class advocacy are important skills for nurses in environmental health practice.

• Risk communication is a critical skill and must acknowledge the outrage factor experienced by communities with envi - ronmental hazards. Federal, state, and local laws and regulations, as well as inter- national treaties, exist to protect the health of people from environmental hazards. Environmental health practice engages multiple disciplines, and nurses are important members of the environmental health team.

• Environmental health practice includes principles of health promotion, disease prevention, and health protection.

• Healthy People 2020 objectives address both targets for the reduction of risk factors and diseases related to environmen- tal causes.

PART 3 Conceptual and Scientific Frameworks

I CLINICAL DECISION-MAKING ACTIVITIES I. Explain why the source of drinking water is important to

investigate in the assessment of an unusually high number

of infertility cases in a community; in increased lead levels

in children from a certain school; and in an outbreak of a

gastrointestinal epidemic in an agricultural community.

2. Discuss the use of the epidemiologic triangle in explaining

the determinants of health.

REFERENCES Agency for Healthcare Research and

Quality: Focus on Research:

Children with Chronic Illness and

Disabilities, AHRO Publication No.

02-M025. Rockvi lle, M D, 2002,

U.S. Department of Health and

Human Services, AHRQ

Publications Clearing House.

American Cancer Society: Cancer

Facts and Figures, 2010. Avai lable

at: http://www.cancer.org .

Accessed June 19, 2014.

American Cancer Society: Cancer Facts & Figures, 2014. Atlan ta GA,

2014, ACS . American Nurse s Association: ANA's

Principles of Environmental Health

in Nursing Practice with

Implementation Strategies. Silver

Spring MD, 2007, Author.

Anney R, Hawi Z, Sheehan K, et al:

Epige netic effects in ADHD:

parent-of-orig in effects in image

sa mple . Am J Med Genet B

Neuropsychiatr Genet 141 (7): 736-

737, 2006. Bassil KL, Vakil C, Sanborn M, et al:

Cancer health effects of pesticides:

systematic revie w. Can Fam

Physician 53 (10) :1704-1711, 2007.

Bailey HD, Fritschi L, Infante-Rivard C,

et al: (20 14) Parental occupational

pesticide exposure and the risk of

childhood leukemia in the offspring:

fin ding s from the childhood

leukemia internationa l consortium.

Int J Cancer 2014. doi: 10 1002/

ijc.28854. Brown RC: Windows of exposure to

pest icides and childhood leukem ia:

an analysis of the current literature.

Birth Defects Res A C/in Mo/

Terato l 70(5):301, 2004 .

Butterfield P, Po stma J: ERRNIE

researc h team: The TERR A

framework: conceptualizing rural

environmental health inequities

through an environmental justice

lens. ANS Adv Nurs Sci 32(2): 107-

117, 2009.

Centers for Disease Control (CDC):

Asthma: data and surveillance,

2012. Avai lable at: http://www

.cdc.gov/asthma/asthm adata.htm.

Accessed March 16, 2014.

Centers for Disease Control (CDC)

Preval ence of autism spectrum

disorde r among ch ildren aged 8

years- Aut ism and Developmental

Di sabi lities Mon itoring Network, 11

sites, United Sta te s, 2010 . MMWR

Survei/1 Summ 63(SS02): 1-21,

2014a . Centers for Disease Control (CDC):

Adolescent and school health:

childhood obesity, 2014b. facts.

http://www. cdc.gov/healthyyouth/

obesity/facts.htm. Accessed March

16, 2014. Clean Air Act: Risk management

programs, Section 112(7). Federal

Register, Part Ill EPA, 40 CFR, Part

68, 2014a. Clean Air Act 1970. http://

www.epa.gov/ai r/caa/. Accessed

June 29, 2014.

Counci l on Linkages Between

Academic and Public Hea lt h

Pract ice: Core Competencies for

Public Health Professionals.

Washington DC, 20 10, Public

Health Foundation/Hea lth

Resources and Services

Admi nist ra t ion.

Department of Health and Human

Services (D HHS) : SAMHSA:

fast facts about children and

mental health, 2005. http://

www.dbhds.virginia .gov/

documents% 5CC FS%5CFact %20

Sheet-About-Chi ldren-and-Menta l-

Health-16.pdf. Accessed March 16,

201 4. Dietert RR, Etzel RA, Chen D, et al:

Workshop to ident ify critical

windows exposure for children's

health: im mune and respiratory

systems work group summary.

Environ Health Perspect

108(Suppl 3) 483- 490, 2000.

Environmental Protection Agency

(EPA): America's children and the

environment, 3 ed (ACE3)

2013-Frequently asked questions,

2013 . http://www.epa.gov/

envirohealth/children/basics/

background.html#4 . Accessed

March 16, 2014.

Environmental Protection Agency:

2009. Available at: http://

www.epa.gov/waterscien ce/fi sh/

advisories/fs2008.html. Accessed

Dece mber 15, 2010.

Environm ental Protection Agency:

Chemica ls in commerce: TSCA

Ch em ical Substance Inventory,

2014 (Last updated 3/13/14)

http://www.epa.gov/oppt/

3. Discover if your jurisdiction has a law or regulation for the

disclosure of lead-based paint or radon levels for personal

property as part of the act of sale for real estate. If your com-

munity do es not, investigate with the government officials

of the community the reasons for the lack of a disclosure

requirement.

existingchemicals/pubs/ tscainventory/basic.html. Accessed

March 16. 2014. Environmental Working Group: Body

Burden- The Pollution in Newborns:

A Benchmark Investigation of

Industrial Ch emicals, Pollu tan ts and

Pesticides in Umbilical Cord Blood,

July 14, 2005. Federa l Insecticide, Fu ngicide, and

Rodenticide Act: 1972. http://

www.epa.gov/oecaagct/lfra.h tml.

Accessed June 29, 20 12.

Gi lden R, Friedmann E, Sattler B,

et al: Potential health effects

related to pesticide use on athletic

f ields. Pub Health Nurs 29(3):198-

207, 2012.

Goldman LR, Koduru SH: Chemicals

in the environment and

developmental toxicity in children:

a public health and policy

perspective. Environ Health

Perspect 108:S443-S448, 2000.

Gulf Oil Spi ll: BP ruined the Gulf, N.d.

http://www.fulf-oi l-sp ill.us/.

Accessed December 29, 2010.

Habre R, Moshier E, Castro W, et al:

The effects of PM 2.5 and its

components from indoor and

outdoor sources on co ugh and

w heeze symptoms in asthmatic

children. J Expo Sci Environ

Epidemiol2014. doi: 101038/

jes.2014 21.

Hi ll WG, Butterfield PG: En vironmental

risk reduct ion for rural children . In

Lee HJ, W inters CA, editors: Rural

Nursing: Concepts, Th eory, and

Practice, ed 2. New York, 2006,

Springer.

Huff M: Ensia Magazine Inte rv iew by

Mary Huff w ith W illiam

McDonough, 2013. http://ensia

.com/interviews/william-mcdon ough

-re making-the-way-we-make

-th ings/. Accessed Ma rch 16, 2014.

Intergovernmental Program on

Cl imate Cha nge: Climate Change

2014: impacts, adaptation, and

vulnerab ility, IPCC Working Group II

Contribution to the 5th assessment

re port, 2014. http://www.who.int/

globalchange/environment/

climatechange-2014-report/en/.

Retrieved Ju ne 10, 20 14.

Jemal A, Siegel R, Xu J, et al: Cancer

statistics 2010. CA Cancer J Clin

60(5):277- 300, 2010 .

Kaiser Foundation: Nurses t rusted

source-Ka iser health tracking poll,

2013. http://kff .org/hea lth-reform/

po 11-f ind i ng/ka i se r-h ea lth-tracki n g

-poll-august-2013/. Accessed March

16, 2014. Landriga n PJ, Rauh VA, Galvez MP:

Environmental ju stice and t he

health of children. Mt Sinai J Med

77(2) 178-187, 2010. doi: 10.1002/

msj.20173. Louv R: No Child Left Inside: Saving

Our Children from Nature-Deficit

Disorder. Chapel Hill, NC. 2005,

Algonquin Books.

Metayer C, Colt JS, Buffler PA, et al:

Exposure to herbicides in house

dust and risk of childhood acute

lymphoblastic leuke m ia. J Expo Sci

Environ Epidemiol 23(4):363-370,

2013. doi: 10. 1038/jes .20 12. 115.

Mood LH: Environmental health

policy: environmental justice . In

Mason DJ, Leavitt JK, editors:

Policy and Politics in Nursing and

Health Care, ed 4. Philadelphia,

2002, Sa un ders.

Myths-Dreams-Symbols: 2006.

Available at: http://www

.mythsdream ssymbols.com/

seattle .html. Accessed December

15, 2010.

O'Brien M: Making Better

Environmental Decisions: An

Alternative to Risk Assessment.

Cambridge, MA, 2000, MIT Press.

Pope AM, Snyder MA, Mood LH,

editors: Nursing, Health and

Environment. Washington, DC,

1995, Inst itute of Medicine,

Nat ional Academy Press.

President's Cancer Pane l: Reducing

Environmental Cancer Risk: What

Can We Do Now, NOTE: th e

actual quote comes from the letter

transmitti ng the report to the

President, Apri l 2010. Annual repo rt

2008-2009. Released 2010. http://

deai nfo.nci. ni h.gov/advisory/pcp/

an nua I Reports/pcp08-09rpt/PC P

_Report_08_09_509.pdf Ret rieved

June 10, 2014.

Public Hea lth, Environment and Social

Determinants of Hea lth (PH E):

20 15. http://www.who.int/phe/

about_us/en/. Accessed February

17, 2015.

Quad Council of Public Health Nursing

Organ izations : Competencies for

Public Health Nursing Practice. Washington DC, 2011, ASTON.

Rawn DF, Roscoe V, Krakalovich T, et al: N-methyl carbamate concentrations and dietary intake estimates fo r apple and grape juices avai lable on the retail market in Canada. Food Addit Contam 21 (6):555-563, 2004.

Ross JA, Olshan AF: Pediatric cancer in the United States: the Children's Oncology Group Epidemiology Research Program. Cancer Epidemic/ Biomarkers Prev 13: 1552- 1 554, 2004.

Sandman PM, Chess C, Hane BJ: Improving Dialogue with Communities. New Brunswick, NJ, 1991, Rutgers University.

Schettler T, Stein J, Reich F, et al: In Harm's Way: Toxic Threats to Development, a Report by Greater Boston Physicians for Social Responsibility, Prepared for a Joint Project with Clean Water. Cambridge, MA, 2000, PSR. Available at: http://www.psr.org/ chapters/boston/resources/ in-harms-way-materials-download .html. Accessed June 29, 2014.

Smargiassi A, Goldberg MS, Wheeler AJ, et al: Associations between personal exposure to air pollutants and lung function tests and cardiovascular indices among children with asthma living near an industrial complex and petroleum refineries. Environ Res 132C:38- 45, 2014. doi: 10.10 16/j.envres .2014.03.030.

Suk WA, Davis EA: Strategies for addressing global environmental health concerns. Ann N Y Acad Sci 1140:40-44, 2008.

Turner MC, Wigle DT, Krewski D: Res idential pesticides and childhood leukemia: a systematic review and meta-analysis. Environ Health Perspect 118(11 :33-41, 2010.

U.S. Department of Health and Human Services: Healthy People 2020, 2010. Available at: http:// www.healthypeople.gov/ 2020topicsobjectives/default.aspx. Accessed June 10, 2014.

U.S. Department of Housing and Urban Development: American Healthy Homes Survey, lead and arsenic findings. April 2011, Office

CHAPTER 10 Environmental Health

i; 1 \~~r ··;: ·. ~:C''r(:·, ii;.- 241 >' ~ ,::,:, I , .. _,, _ .. _ .J- .~- 1- - ""

of Healthy Homes and Lead Hazard Control.

Wigle OT, Turner MC, Krewski D: A systematic review and meta-analysis of childhood le ukemia and parental occupational pesticide exposure. Environ Health Perspect 117(10):1505-1513, 2009.

Un ited Nations University: WHO quote found from 1993 document, 1993. http ://unu .edu/publications/ articles/environmental-health -governance-for-sustainable -d evelopment.html. Retrieved June 7, 2014.

Wingspread Statement on the Precautionary Principle. Racine, WI, 1998. Available at: http://www.gdrc .org/u-gov/precaution-3. htm l. Retrieved to March 12, 2015.

U.S. Department of Housing and Urban Development: American Healthy Homes Survey, lead and arsenic findings, April 20 11, Office of Healthy Homes and Lead Hazard Control. http://portal.hud.gov/ hudportal/documents/huddoc ?id=AHHS_REPORT.pdf. Accessed February 17, 2015.

World Heal th Organization: Public Health and the Environm ent. Public Health, Environment, and Social Determinants of Health (PHE), http://www .who.int/phe/about_us/en/. Accessed February 17, 2015.

World Health Organization: Climate Change and Huma n Health, 2014. http://www.who.i nt/globalchange/ en/. Accessed March 16, 2014b.

World Hea lt h Organization: Fact File: 10 facts on mental health, N.d. http://www.who.int/features/ factfiles/mental_health/mental _health_facts/en/ Accessed March 16, 2014.

Yoder JS, Wallace RM , Collier SA, et al: Cryptosporidiosis surve illance-Un ited States, 2009-2010. Centers for Disease Control and Prevention (CDC). MMWR Survei/1 Summ 61 (5): 1-12, 20 12 . http://www.cdc.gov/ mmwr/preview/mmwrhtml/ ss6105a1 .htm. Accessed June 29, 2014.

Genomics 1n Public Health Nursing*

Elke Jones Zschaebitz, DNP, FNP-BC Elke Jo nes Zschaebitz is a nu rse practitione r who has wo rked in the fields of school health, pediatrics. and wo men's health, as w

ell as in a telehealth

practice in primary care. She received her BSN from Villanova Unive rsity, her MSN-FNP from Midwestern State University in Wichita Falls Texas.

and her DNP fro m Duquesne University in Pittsburgh, Penn sylvania. She currently is employed at the University of Virginia Stu dent He alth Center in

Charlottesville, VA, and is part-tim e faculty for the Fa mily Nurse Practitioner program at Georgetown Un ive rsity.

Jeanette Lancaster, PhD, RN, FAAN Dr. Lancaster is Profe ssor and Dean Eme ri ta of Nurs ing at the Unive rsity of Virg inia. She has edited th is book with Dr. Ma rcia

Stan hope thro ugh its

previous eight editions.

e Evolve Website http://evolve.elsevier.com/Stanhope • Healthy People 2020

• WebLinks

• Glossary • Answers to Practice Application

• Quiz

OBJECTIVES ... ~ - ------ - -·- . . - - ----------------------- -- . - ------------- After reading this chapter, the student should be able to do the

following: 1. Define key terms related to genetics and genomics.

2. Discuss the history of genomics and its integration into

public health nursing. 3. Describe the relationship between genomics, genetics, and

nursing.

KEY TERMS

4. Explain the core competencies related to genomics that

nurses and selected other public health professionals

should integrate into their practice.

5. Describe at least three potential implications of persons

knowing their genetic information on clients, families, and

communities.

............... ~ ...... --..= .. --------~-----~ --~ ------~~-----------

--------- ----

DNA,p. 245 epigenetics, p. 253 family health history, p. 251

genes, p. 245 genome, p. 243 genomics, p. 243 genetics, p. 243

genetic susceptibility, p. 254

Human Genome Project, p. 244

multifactorial diseases, p. 253

mutations, p. 245

pedigree, p. 251 -See Glossary for definitions

*Special ~hanks a~e _given to _Gia Mudd-M~rti~, RN, MPH, Ph_D'. Assistant Professor, College of Nursing , University of Kentucky for reviewing the

m anuscnpt, prov1dmg pubhc health nursmg mput, and prov1dmg two of the case examples for the 8th edition of the chapter.

242